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UNIVERSITY OF MINNESOTA

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UNIVERSITY OF MINNESOTA

THE JOURNAL

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MENTAL SCIENCE.

J. R. Lord) C.B.E., M.B.
G. Douglas MoRae, M.D.

EDITORS *

Henry Devine, O.B.E., M.D.
W. R. Dawson, O.B.E., M.D.

VOL. LXVI.

LONDON:

J. & A. CHURCHILL.

7, GREAT MARLBOROUGH STREET.

MDCCCCXX.

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“ In adopting our title of the Journal of Mental Science t published by authority
of the Medico-Psychological Association , we profess that we cultivate in our pages
mental science of a particular kind, namely, such mental science as appertains
to medical men who are engaged in the treatment of the insane. But it has
been objected that the term mental science is inapplicable, and that the term
mental physiology or mental pathology, or psychology, or psychiatry (a term
much affected by our German brethren), would have been more correct and ap¬
propriate ; and that, moreover, we do not deal in mental science, which is pro¬
perly the sphere of the aspiring metaphysical intellect. If mental science is
strictly synonymous with metaphysics, these objections are certainly valid; for
although we do not eschew metaphysical discussion, the aim of this Journal is
certainly bent upon more attainable objects than the pursuit of those recondite
inquiries which have occupied the most ambitious intellects from the time of
Plato to the present, with so much labour and so little result. But while we
admit that metaphysics may be called one department of mental science, we main¬
tain that mental physiology and mental pathology are also mental science under
a different aspect. While metaphysics may be called speculative mental science,
mental physiology and pathology, with their vast range of inquiry into insanity,
education, crime, and all things which tend to preserve mental health, or to pro¬
duce mental disease, are not less questions of mental science in its practical, that
is in its sociological point of view. If it were not unjust to high mathematics
to compare it in any way with abstruse metaphysics, it would illustrate our
meaning to say that our practical mental science would fairly bear the same rela¬
tion to the mental science of the metaphysicians as applied mathematics bears to
the pure science. In both instances the aim of the pure science is the attainment
of abstract truth; its utility, however, frequently going no further than to serve
# as a gymnasium for the intellect. In both instances the mixed science aims at,
’• "and, etftfefc^rajtstfns immediate practical results of the greatest utility

• ip fiit*yeffar^2of«tf»alil^iIct; Jve therefore maintain that our Journal is not inaptly
calred*tlie JournAl 6f*Men\hl Science, although the science may only attempt to
/• Wt{h;^plpgi<3d.$iid medical inquiries, relating either to the preservation of

l \ flie? health gnftldjor to the amelioration or cure of its diseases; and although

# nof sbhVihg* thfe ‘height of abstruse metaphysics, we only aim at such meta-
• * .physical •knowledge as may be available to our purposes, as the mechanician uses
V oNmathematics. This is our view of the kind of mental science

• • Which «ph/feieians ^engaged in the grave responsibility of caring for the mental
health of their fellow-men may, in all modesty, pretend to cultivate; and while
we cannot doubt that all additions to our certain knowledge in the speculative
department of the science will be great gain, the necessities of duty and of danger
must ever compel us to pursue that knowledge which is to be obtained in the
practical departments of science with the earnestness of real workmen. The cap¬
tain of a ship would be none the worse for being well acquainted with the higher
branches of astronomical science, but it is the practical part of that science as it
is applicable to navigation which he is compelled to study.’ 1 —5>V J. C. BueknUl %
M.D ., F.R.S.

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TflK

MEDICO-PSYCHOLOGICAL ASSOCIATION
OF GREAT BRITAIN AND IRELAND.

THE COUNCIL AND OFFICERS. 1919-20.

president.— BEDFORD PIERCE, M.D., F.R.C.P.

president ELECT.— WILLIAM F. MENZLES, M.D.

ex-president.— JOHN KEAT, O.B.E., M.D., F.R.C.P.

treasurer.— JAMES CHAMBERS, M.A., M.D.

f JOHN R. LORD, C.B.E., M.B.

editors OP journal fl - DEVINE, O.B.E., M.D, F.R.C.P.

EDITORS OP journal q D0 UGLAS McK AE, M.b., F.R.C.P.Edin.

IW. R. DAWSON, C.B.E., M.D., F.R.C.P.I.

DIVISIONAL SECRETARY FOR SOUTH-EASTERN DIVI8ION.

J. NOEL SERGEANT, M.B.

DIVISIONAL SECRETARY FOR SOUTH-WESTERN DIVISION.

G. N. BARTLETT, M.B.

DIVISIONAL SECRETARY FOR NORTHERN AND MIDLAND DIVISION.

T. STEWART ADAIR, M.D.

DIVISIONAL SECRETARY FOR SCOTTISH DIVISION.

KOBT. B. CAMPBELL, M.D., F.R.C.P.

DIVISIONAL SECRETARY FOR IRISH DIVISION.

RICHARD R. LEEPER, F.R.C.8.

GENERAL SECRETARY.

R. WORTH, O.B.E., M.B., B.S.Durh., M.R.C.S., L.B.C.P.Lond.

CHAIRMAN OF PARLIAMENTARY COMMITTEE.

fl. WOLSELEY-LKWIS, M.D., F.R.C.S.

SECRETARY OF PARLIAMENTARY COMMITTEE.

I*. H. COLE, M.D., F.R.C.P.

(both appointed by Parliamentary Committee, and with teats on Council.)

CHAIRMAN OF EDUCATIONAL COMMITTEE.

MAURICE CRAIG, C.B.E ., M.D., F.R.C.P., M.P.C.
vice-chairman.— M. A. COLLINS, O.B.E ., M.D.

SECRETARY OF EDUCATIONAL COMMITTEE.

A. W. DANIEL, B.A., M.D.

(Appointed by Educational Committee, and with seats on Council).
registrar.— ALFRED A. MILLER, M.B.

MBMBBR8 OP COUNCIL.

REPRESENTATIVE.

R. ARMSTRONG-JONE8
DAVID BOWER
MAURICE CRAIG
A. W. DANIEL
H. T. S. AVELINE
H. C. MACBKYAN
J. W. GEDDES
H. J. MACKENZIE
L. R. OSWALD
J. H. SKEEN

j-8.E. Div.

}S.W. Div.
}N.&M. Div.
} Scotland.

REPRESENTATIVE.

M. J. NOLAN l.

J. MILLS ; Irrland.

NOMINATED.

HELEN BOYLE
K. D. HOTCHKI8
DAVID ORR
G. E. SHUTTLEWORTH
JOHN G. SMITH.
DAVID G. THOMSON.
[The above form the Couneil.]

EXAMINERS.

RNGLAND

fR. H. STEEN, M.D.. M.R.C.P.

V’ Q M 1 pf TER ' PHliLIP8, M D -> BS - M.R.C.P.Lond.

SCOTLAND { £• 0SW A A L L E D XA 5.D E L ^.M D-,C - M - Edi11 -

fM. J. NOLAN, L.R.C.P.&S.I., M.P.C.

IRELAND F. E. KAINSFORD, M.D., B.A.Dubl., L.R.C.P.I.,
L.a. 0.1 .ao.E,

Examiners for the Nursing Certificate of the Association :

Final .—HENRY DEVINE, O.B.E., M.D., B.8., F.R.C.P.. M.B C 8 M P C • N T
KERR, M.D., C.M.Edin.; JO&N bflLLS, M.b“|!a., r’.U.I.
JVs/i«i»ww.-GEORGE DUNLOP ROBERTSON, L.B.C.S. ft P.Edin., Dipl. Psych, i
H. BROUGHAM LEECH, M.D., B Ch.Dublin; PATRICK O’DOHERTY;

BA, M.B., B.Ch., B.U.I.

F. H. EDWARDS, M.D., M.R.C.P. AVDIT0 “’ q f BAEH AM, M.A., M.D.Csmb.

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PARLIAMENTARY COMMITTEE,

FLETCHER BEACH.

J. 8HAW BOLTON.

A. HELEN BOYLE.

R. H. COLE.

M. A. COLLINS.
MAURICE CRAIG.

R. EAGER.

JOHN KKAY (ex officio ).
R. L. LANGDON-DOWN,
R. R. LEEPER.

J. R. LORD.

W. F. MENZIES..

A. MILLER.

W. F. NELIS.
BEDFORD PIERCE.

NATHAN RAW.

G. M. ROBERTSON.

J. NOEL SERGEANT.

G. E. 8HUTTLKWORTH.
R. PERCY SMITH.

J. G. SOUTAR.

J. BEVERIDGE 8PENCE.
R. H. STEEN.

ROTHSAY C. STEWART.
F. R. P. TAYLOR.
DAVID G. THOMSON.
ERNEST W. WHITE.

J. R. WHITWELL.

H. WOL8ELEY-LEWI8.

EDUCATIONAL COMMITTEE.

FLETCHER BEACH.

1. R. H. COLE.

M. A. COLL1N8
T. P. COWEN.

2. MAURICE CRAIG.

A. W. DANIEL.

R. EAGER.

3. B. HART.

4. JOHN KEAY.

W. F. MENZIES.

W. F. NELIS.

BEDFORD PIERCE.

5. GEORGE M. ROBERTSON.

R. PERCY SMITH.

J. G. SOUTAR.

J. BEVERIDGE SPENCE.

6. ROBERT H. STEEN.
FREDERICK R. P. TAYLOR.
DAVID G. THOMSON.

J. R. WHITWELL.

LIBRARY

FLETCHER BEACH.

HELEN BOYLE.

M. A. COLLINS.

HENRY DEVINE.

BERNARD HART.

THEO. B. HYSLOP.

RESEARCH

T. 8TEWART ADAIR.

J. SHAW BOLTON.

J. CHAMBERS.

M. A. COLLIN8.

H. DEVINE.

E. GOODALL.

JOHN KEAY.

J. R. LORD.

COMMITTEE.

JOHN KEAY (cm officio},

E. MAPOTHER.

HENRY KAYNER (Chairman).
R. H. STEEN ( Secretary ).

W. H. B. STODDART.

DAVID G. THOMSON.

COMMITTEE.

DAVID ORR.

FORD ROBERTSON.
R. G. ROWS.

R. PERCY SMITH.
R. H. STEEN.

D. G. THOMSON.
W. J. TULLOCH.

Lectures at : — (1) St. Mary’s Hospital, London; (2) Guy’s Hospital; (3) University
College, London ; (4) Lecturer at School of Medicine, Royal Colleges and Medical
College for Women, Edinburgh; (6) University of Edinburgh and Medical College
for Women, Edinburgh; (6) Sing’s College Hospital. *

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Ill

LIST OF CHAIRMEN.

1841. Dr. Blake, Nottingham.

1842. Dr. da Vitrl, Lancaster.

1843. Dr. Conolly, Hanwell.

}844. Dr. Thurnam, York Retreat.

1847. Dr. Wintle, Warneford House, Oxford.

1861. Dr. Conolly, Hanwell.

1862. Dr. Wintle, Warneford House.

LIST OF PRESIDENTS.

1864. A. J. Sutherland, M.D., St. Luke’s Hospital, London,

1866. J. Thurnam, M.D., Wilts County Asylum.

1866. J. Hitchman, M.D., Derby County Asylum.

1867. Forbes Winslow, M.D., Sussex House, Hammersmith.

1868. John Conolly, M.D., County Asylum, Hanwell.

1869. Sir Charles Hastings, D.C.L.

1860. J. C. Bucknill, M.D., Devon County Asylum.

1861. Joseph Lalor, M.D., Richmond Asylum, Dublin.

1862. John Kirkman, M.D., Suffolk County Asylum.

1863. David Skae, M.D., Royal Edinburgh Asylum.

1864. Henry Munro, M.D., Brook House, Clapton.

1866. Wm. Wood, M.D., Kensington House.

1866. W. A. F. Browne, M.D., Commissioner in Lunacy for Scotland.

1867. C. A. Lockhart Robertson, M.D., Haywards Heath Asylum.

1868. W. H. O. Sankey, M.D., Sandywell Park, Cheltenham.

1869. T. Lay cock, M.D., Edinburgh.

1870. Robert Boyd, M.D., County Asylum, Wells.

1871. Henry Maudsley, M.D., The Lawn, Hanwell.

1872. Sir James Coxe, M.D., Commissioner in Lunacy for Scotland.

1873. Harrington Tuke, M.D., Manor House, Chiswick.

1874. T. L. Rogers, M.D., County Asylum, Rainhill.

1875. J. F. Duncan, M.D., Dublin.

1876. W. H. Parsey, M.D., Warwick County Asylum.

1877. G. Fielding Blandford, M.D., London.

1878. Sir J. Crichton-Browne, M.D., Lord Chancellor’s Visitor.

1879. J. A. Lush, M.D., Fisherton House, Salisbury.

1880. G. W. Mould,M.R.C.S., Royal Asylum, Cheadle.

1881. D. Hack Tuke, M.D., London.

1882. Sir W. T. Guirdner, M.D., Glasgow.

1883. W. Orange, M.D., State Criminal Lunatic Asylum, Broadmoor.

1884. Henry Rayner, M.D., County Asylum, Hanwell.

1885. J. A. Eames, M.D., District Asylum, Cork.

1886. Sir Geo. H. Savage, M.D., Bethlem Royal Hospital.

1887. Sir Fred. Needham, M.D., Barn wood House, Gloucester.

1888. Sir T. S. Clouston, M.D., Royal Edinburgh Asylum.

1889. H. Hayes Newington, F.R.C.P., Ticehurst, Sussex.

1890. David Yellowlees, M.D., Gartnavel Asylum, Glasgow.

1891. E. B. Whitcombe, M.R.C.S., City Asylum, Birmingham.

1892. Robert Baker, M.D., The Retreat, York.

1893. J. Murray Lindsay, M.D., County Asylum, Derby.

1894. Conolly Norman, F.R.C.P.I., Richmond Asylum, Dublin.

1895. David Nicolson, C.B.,M.D., State Criminal Lunatic Asylum, Broadmoor.

1896. William Julius Mickle, M.D., Grove Hall Asylum, Bow.

1897. Thomas W. McDowall, M.D., Morpeth, Northumberland.

1898. A. R. Urquhart, M.D., James Murray’s Royal Asylum, Perth.

1899. J. B. Spence, M.D., Burntwood Asylum, nr. Lichfield, Staffordshire.

1900. Fletcher Beach, M.B., 79, Wimpole Street, W. 1.

1901. Oscar T. Woods, M.D., District Asylum, Cork, Ireland.

1902 J. Wiglesworth, M.D., F.R.C.P., Rainhill Asylum, near Liverpool.

1903. Ernest W. White, 0.i?.2?., M.B.,M.R.C.P. f Betley House, nr. Shrewsbury.

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1904. R. Percy Smith, M.D., F.R.C.P., 36, Queen Anne Street, Cavendish

Square, London, W. 1.

1905. T. Outterson Wood, M.D., F.R.C.P., 40, Margaret Street, Cavendish

Square, London, W. 1.

1906. Sir Robert Arm strong-Jones, C.B.E ., M.D.Lond., B.S., P.R.C.P.,

F.R.C.S.Eng., Claybnry Asylum, Woodford Bridge, Essex.

1907. P. W. MacDonald, M.l)., County Asylum, Dorchester.

1908. Chas. A. Mercier, M.D., F.R.C.P., F.R.C.S., 34, Wimpole Street, London,

W. 1.

1909. W. Bevan-Lewis, M.Sc., L.R.C.P., late Medical Director, West Riding

Asylum, Wakefield.

1910. John Mncpherson, M.D., F.R.C.P.Edin., Commissioner in Lunacy, 8,

Damaway Street, Edinburgh.

1911. Wm. R. Dawson, O.B.E ., B.A., M.D., F.R.C.P.I., D.P.H., Inspector of

Lunatic Asylums, Dublin Castle, Dublin.

1912. J. Greig Soutar, M.B., Barnwood House, Gloucester.

1913. James Chambers, M.D., M.Ch., The Priory, Roehampton, S.W.

1914-18. David G. Thomson, C.B.E,, M.D., C.M.Edin., County Aaylum, Thorpe,

Norfolk.

1918. John Keay, C.B.E., M.D., C.M., F.R.C.P., Edinburgh War Hospital,

Baugour.

1919. Bedford Pierce, M.D., F.R.C.P., The Retreat, York.

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Honorary and Corresponding Members.

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HONORARY MEMBERS.

1890. Atlbutt, Sir T. Clifford, K.C.B., M.D., D.Sc., LL.D., F.R.C.P., F.R.S.,
. Regius Professor of Physic, Univ. Camb., St. Radegund’s, Cambridge.

1881. Benedikt, Prof. M., Wien, ix Marianngasse 1, Vienna.

1918. Bevan-Lewis, William, M.Sc.Leeds, M.R.C.S., L.R.C.P.Lond., 22,
Cromwell Road, Hove. (President, 1909-10.)

1907. Bianchi, Prof. Leonardo, Manicomio Provincial® di Napoli. Musee N. 3,
Naples, Italy. (Corr. Mem., 1896.)

1900. Blurner, Q. Alder, M.D., L.R.C.P.Edin., Butler Hospital, Providence,
U.S.A. (Ord. Mem., 1890.)

1900. Bresler, Johannes, M.D., 0berart2t, Luben in Schlesien, Germany.
( Corr. Mem, 1896.)

1902. Brash, Edward N., M.D., Sheppard and Enoch Pratt Hospital, Towson,
Maryland, U.S.A.

1917. Colies, John Mayne, LL.D. (Univ. Dub.), K.C., J.P., Registrar in Lunacy

(Supreme Court of Judicature in Ireland), Lunacy Office, Four
Courts, Dublin.

1909. Collins, Sir William J., D.L., M.D., M.S., B.Sc.Lond., F.R.C.S.Eng.,
Meads End, Eastbourne, Sussex.

1912. Considine, Thomas Ivory, F.R.C.S.I., L.R.C.P.I., Inspector of Lunatic
Asylums, Ireland, Office of Lunatic Asylums, Dublin Castle, Dublin.

1918. Cooke, Sir Edward Marriott, K.B.E., M.D., M.R.C.S.Eng., Commissioner

in Lunacy, 69, Onslow Square, London, S.W. 7.

1902. Coupland, Sidney, M.D., F.R.C.P.Lond., Commissioner of the Board of
Control, " Plas Gwyu,” Frogual, Hampstead, London, N.W. 3.

1876. Orichton-Browne, Sir J., M.D.Edin., LL.D., D.Sc., F.R.S., Lord
Chancellor’s Visitor, Royal Courts of Justice, Strand, London,
W.C. 2., and 45, Hans Place, London, S.W. 1. (President, 1878.)
1911. Donkin, Sir Horatio Bryan, M.A., M.D.Oxon., F.R.C.P.Lond. (Medloal
Adviser to Prison Commissioners and Director of Convict Prisons),
28, Hyde Park Street, London, W. 2.

1896. Ferrier, Sir David, M.A., M.D., LL.D., F.R.C.P., F.R.S., 34, Cavendish
Square, London, W. 1.

1872. Fraser, John, M.B., C.M., F.R.C.P.E., Formerly Commissioner in
Lunacy, 64, Great King Street, Edinburgh.

1909. Kraetfelin, Dr. Emil, Professor of Psychiatry, The University, Mfinich.

1910. Macpherson, John, M.D., F.R.C.P.Edin., Commissioner in Lunacy, 8,

Darnaway Street, Edinburgh. (Pbbsidbnt, 1910-11.) ( Ordinary
Member from 1886.)

1911. Moeli, Prof. Dr. Karl, Director, Herzberge Asylum, Berlin.

1889. Needham, Sir Frederick, M.D.St. And., M.R.C.P.Edin., M.R.C.S.Eng.,
Commissioner of the Board of Control, 19, Campden Hill Square,
Kensingtou, London, W. 8. (Pbbsidhnt, 1887.)

1909. Obersteiner, Dr. Heinrich, Professor of Neurology, The University, Vienna.
1881. Peeters, M., M.D., Gheel, Belgium.

1900. Ritti, Ant., 68, Boulevard Exelmans, Paris. (Corr. Mem., 1890.)

1911. Semelaigne, Rln6, M.D.Paris, Secretaire des Stances de la Soci6t6

Medico-Psychologique de Paris, 18, Avenue de Madrid, Neuilly,
Seine, France. ( Corresponding Member from 1893.)

1901. Toulouse, Dr. Edouard, Directeur du Lab or a to ire de Psychologic experi¬

mental k l’Ecole des Hantes Etudes Paris et M6decin en chef de
l’Asile dc Villejuif, Seine, France.

1910. Trevor, Arthur Hill, Esq., B.A.Oxon., of the Inner Temple, Barrister at

Law, Commissioner of the Board of Control, 4, Albemarle Street,
London, W. 1.

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CORRESPONDING MEMBERS.

1911. Boedeker, Prof. Dr. Justus Karl Edmund, Privat Docent and Director*
Fichtenhof Asylum, Schlachtensee, Berlin.

1897. Boschan, Dr. Q., Stettin, Germany.

1904. Carolett, Wilfrid, Manicomio de Las Corts, Barcelona, Spain.

1896. Cowan, F. M., M.D., 109, Perponcher Straat, The Hague, Holland.

1911. Falkenberg, Dr. Wilbelm, Sanit&tstrat, Direktor der Berliner staedtischen
Torenanstalt Buch (Bez. Potsdam).

1907. Ferrari, Giulio Cesare, M.D., Director of the Manicomio Provincials,
Imola, Bologna, Italy.

1911. Friedlander, Prof. Dr. Adolf Albrecht, Director of the Hohe Mark Klinik*
nr. Frankfort.

1901. Gomm&s, Dr. Marcel, 6, Rue Parrot, Paris XII.

1909. Pilcz, Dr. Alexander, YIII/2 Alserstrasse 43, Wien, Austria.

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vii

MEMBERS OF THE ASSOCIATION.

Alphabetical Liet of Members of the Association on December 31 st, 1918, with
the year in which they joined .

1900. Abbott, Henry Kingsmill, B.A., M.D.Dub., D.P.H.Ire!., Medical Superin¬
tendent, Hants County Asylum, Fareham.

1891. Adair, Thomas Stewart, M.D., C.M.Edin., F.R.M.S., Medical Superin¬
tendent, Storthes Hall Asylum, Kirk burton, near Huddersfield.
{Hon. Sec . N . and M. Division since 1908.)

1910. Adam, George Henry, M.R.C.S., L.R.C.P.Lond., Manager and Medical
Superintendent, West Mailing Place, Kent.

1913. Adams, John Barfield, L.R.C.P.AS.Edin., M.P.C., 119, Redland Road,
Bristol.

1868. Adams, Josiah O., M.D.Durh., F.R.C.S.Eng., J.P., 117, Cazenove Road,
Stamford Hill, Loudon, N. 16.

1919. Adey, J. K., M.B., C.M.Melbourne, Receiving House, Royal Park,
Melbourne, Australia.

1886. Agar, S. Hollingsworth, jun., B.A.Cantab., M.R.C.S.Eng., L.S.A., Hurst
House, Henley-in-Arden.

1899. Alexander, Hugh de Maine, M.D., C.M.Edin*, Medical Superintendent,
Aberdeen City District Asylum, Kingseat, Newmachar, Aberdeen.
1899. Allmann, Dorah Elizabeth, M.B., B.Ch.R.U.I., Assistant Medical Officer,
District Asylum, Armagh.

1908. Anderson, James Richard Sumner, M.B., Ch.B.Glas., Senior Assistant

Medical Officer, Cumberland and Westmorland Asylum, Garlands,
Carlisle.

1898. Anderson, John Sewell, M.R.C.S., L.R.C.P.Lond., Senior Assistant
Medical Officer, Hull City Asylum, Willerby,near Hull.

1918. Anderson, William Kirkpatrick, M.B., Ch.B.Glas., Dykebar War Hospital,

Paisley ; 2, Woodside Crescent, Glasgow.

1912. Annandale, James Scott, M.B., Ch.B.Edin., Ayr District Asylum, Ayr.

1919. Anthony, Mark, L.R.C.P.I., L.R.C.S.I., Assistant Medical Officer, Bucks

County Asylum, Stone, Aylesbury.

1912. Aplhorp, Frederick William, M.R.C.S.Eng., L.R.C.P.Edin., M.P.C.,
Senior Medical Officer, St. George’s Retreat, Ravensworth, Burgess
Hill.

1904. Archdale, Mervyn Alex., M.B., B.S.Durh., Medical Superintendent,

County Mental Hospital, Cambridge.

1905. Archdall, Mervyn Thomas, L.R.C.P.&S.Edin., L.S.A.Lond., Brynn-y-

Nenadd Hall, Llanfairfechan, N. Wales.

1918. Archibald, Alexander John, M.B., Ch.B.Glas., Acting Medical Superin¬
tendent, Argyll and Bute District Asylum, Lochgilphead, Argyllshire.
1918. Archibald, Madeline, L.R.C.P., L.R.C.S., Assistant Medical Officer, Argyll
and Bute District Asylum, Lochgilphead.

1882. Armstrong-Jones, Sir Robert, C.BJS ., M.D.Lond., B.S., F.R.C.P.,
F.R.C.S.Eng., 105, Harley Street, W. 1 (and PlAs Dinas, Carnarvon,
North Wales). (Oen. Secretary from 1897 to 1906.) (Prbsidbkt,
1906-7.)

1910. Auden, G. A., M.A., M.D., B.C., D.P.H.Cantab., F.R.C.P.Lond., F.R.C.P..

F.S.A., Medical Superintendent, Educational Offices, Edmund
Street, Birmingham.

1891. Aveline, Henry T. S., M.D.Durh., M.R.C.S., L.R.C.P.Lond„ M.P.C.,
Medical Superintendent, County Asylum, Cotford, near Taunton,
Somerset. (Hon. Sec . for S. W. Division , 1905-11.)

1903. Bailey, William Henry, M.D.Lond., M.R.C.S.Eng:, L.S.A., D.P.H.Lond.,
Featherstoue Hall, Southall, Middlesex.

1909. Bain, John, M.A., M.B., B.Ch.Glasg. (address uncommunicated).

1918. fiainbridge, Charles Frederick, M.B., Ch.B.Edin., Assistant Medical

Officer, Devon Mental Hospital, Exminster.

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viii Members of the Association.

1906. Baird, Harvey, M.D., Ch.B.Edin., Periteau, Winchelsea, Sussex.

1878. Baker, H. Morton, M.B., C.M.Edin., 7, Belsize Square, London, N.W. 3.
1888. Baker, Sir John, M.D., C.M.Aberd., Medical Superintendent, State
Asylum, Broadmoor, Berks.

1904. Barham, Guy Foster, M.A., M.D., B.C.Cantab., M.R.C.S., L.R.C.P.Lond.,
Medical Superintendent, Clay bury Asylum, Woodford Bridge, Essex.
1919. Barkas, Mary Rush ton, M.R.C.S., L.R.C.P.Lond., Temporary Assistant
Medical Officer, Bethlem Royal Hospital, Lambeth, London, S.E. 1;
and 46, Connaught Street, London, W. 2.

1918. Barkley, James Morgan, M.B., Ch.B.Edin. (Senior Medical Officer,
Bracebridge Asylum, Lincolnshire).

1910. Bartlett, George Norton, M.B., B.S.Lond., M.R.C.8., I^R.C.P.Lond.,
Medical Superintendent, City Asylum, Exeter.

1901. Baskin, J. Lougheed, M.D.Brux., L.R.C. P.&S.Edin., L.R.F.P.AS.Glas.

1902. Baugh, Leonard D. H., M.B., Ch.B.Edin., The Plcasaunce, York.

1874. Beach, Fletcher, M.B., F.R.C.P.Loud., formerly Medical Superintendent ,

Darenth Asylum , Dartford ; 5, De Crespigny Park, Denmark Hill,
S.E. 5. {Secretary Parliamentary Committee, 1896-1906. General
Secretary , 1889-1896. President, 1900.)

1892. Beadles,Cecil F., M.R.C.S., L.R.C.P.Lond., Gresham House, Egham Hill,
Egham.

1913. Bedford, Percy William Page, M.B., Ch.B.Edin., County Asylum, Lan¬

caster.

1909. Beeley, Arthur, M.Sc.Leeds, M.D., B.S.Lond., M.R.C.S., L.R.C.P.Lond.,
D.P.H.Cauib. {Assistant Medical Officer, E. Sussex Educational
Committee), Windybank, King Henry’s Road, Lewes.

1914. Bennett, James Wodderspoon, M.R.C.S., L.R.C.P.Lond., County Mental

Hospital, Stafford.

1912. Benson, Henry Porter D’Arcy, M.D., C.M.Edin., M.R.C.P., F.R.C.8.

Edin., Medical Superintendent, Farnham House, Finelas, Dublin.
1914. Benson, John Robinson, F.R.C.S.Eng., L.R.C.P.Lond., Resident Physi¬
cian and Proprietor, Fiddington House, Market Lavington, Wilts.

1899. Beresford, Edwyn H., M.R.C.S., L.R.C.P.Lond., Medical Superintendent,

Tooting Bee Asylum, Tooting, London, S.W. 17.

1912. Berncastle, Herbert M., M.R.C.S.Eng., L.R.C. P.Lond., Assistant Medical,
Officer, Croydon Mental Hospital, Warlingham, Surrey.

1894. Blacbford, James Vincent, C.B.E., M.D., B.S.Durh., M.R.C.S., L.R.C.P.
Lond., M.P.C., City Asylum, Fishponds, Bristol.

1918. Black, Robert Sinclair, M.A.Edin., M.D., C.M.Aberd., D.P.H., M.P.C.,

Medical Supt., Pietermaritzburg Mental Hospital, Natal, South
Africa.

1898. Blair, David, M.A., M.D., C.M.Glasg., County Asylum, Lancaster.

1919. Blake, Stanley,L.R.C.P.&S.I.AL.M., Assistant Medical Officer, Portrane

Asylum, Donabnte, Ireland.

1919. Blakiston, Frederick Cairns, M.R.C.S., L.R.C.P., Medical Superintendent,
Isle of Man Asylum.

1897. Blandford, Joseph John Guthrie, B.A., D.P.H.Camb., M.R.C.S., L.R.C.P.
Lond., Whallcy Asylum, Blackburn.

1918. Blandford, Walter Folliott, B.A.Camb., M.R.C.S., L.R.C.P.Lond.,
Temporary Assistant Medical Officer, Caterham Asylum, Caterham,
Surrey.

1904. Bodvel- Roberts, Hugh Frank, M. A. Can tab., M.R.C.S., L.R.C.P.Lond.,
L.S.A., Napsbury Mental Hospital, near St. Albans, Herts.

1900. Bolton, Joseph Shaw, M.D., B.S., D.Sc., F.R.C.P.Lond., Medical Super¬

intendent, West Riding Asylum, Wakefield.

1892. Bond, Charles Hubert, D.Sc., M.D., C.M.Edin., F.R.C.P.Lond., M.P.C.,
Commissioner of the Board of Control, 66, Victoria Street, London,
S.W. 1. (Eon. General Secretaiy , 1906-12.)

1918. Bower, Cedric William, L.M.S.S.A., Joint Medical Officer, Springfield
House, near Bedford.

1877. Bower, David, M.D., C.M.Aber., Springfield House, Bedford. ( Chairman,
Parliamentary Committee , 1907-1910.)

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Digitized by

1877. Bowes, John Ireland, M.R.C.S.Eng., L.S.A. (address uncoinmnnic&ted.)

1917. Bowie, Edgar Ormond, LJt.H.Dub., Dip. Grant Med. Coll. Bombay,

L.M.Coombe, Dublin; c/o W. H. Halliburton, Esq., 18, South
Frederick Street, Dublin.

1900. Bowles, Alfred, M.R.C.S., L.B.C.P.Lond., 10, South Cliff, Eastbourne.
1896. Boycott, Arthur N., M.D.Loud., M.R.C.S., L.B.C.P.Lond., Medical
Superintendent, Herts County Asylum, Hill End, St. Albans, Herts.
(Hon. Sec. for S.-JE . Division, 1900-05.)

1898. Boyle, A. Helen A., M.D.Brux., L.R.C.P.&S.Edin., 9, The Drive, Hove,
Brighton.

1888. Boys, A. H., L.R.C.P.Edin., M.R.C.S.Eng., L.S.A.Lond., The White
House, St. Albans.

1891. Braine-Hartuell, George M. P., M.R.C.S., L.B.C.P.Lond., Medical
Superintendent, County and City Asylum, Powiek, Worcester.

1911. Brander, John, M.B., C.B.Edin., Assistant Medical Officer, London

County Mental Hospital, Bexley, Kent.

1919. Branthwaite, Robert Welsh, C.B., M.D.Brux., M.R.C.S., L.R.C.P.,
D.P.H.Lond., Commissioner of the Board of Control, 66, Victoria
Street, London, S.W. 1.

1918. Brend, William Alfred, M.D.Loud., 14, Bolingbroke Grove, London,

S.W. 11.

1906. Brown, Harry Egerton, M.D., Ch.B.Glasg., M.P.C., Mental Hospital,
Fort Beaufort, Cape Province, S. Africa.

1908. Brown, Robert Cunyngham, O.B.E.. M.D., B.S.Durh. (General Board of
Lunacy, 25, Palmerston Place, Edinburgh); Administrator, Spring-
burn and Woodside Central Hospital, Glasgow.

1908. Brown, R. Dods, M.1)., Ch.B., F.R.C.P., Dipl. Psych., D.P.H.Edin.,
Medical Superintendent, The Royal Asylum, Aberdeen.

1912. Brown, William, M.D., C.M.Glas., M.P.C., District Medical Officer,

Adviser in Lunacy to Bristol Magistrates, 1, Manor Road, Fish¬
ponds, Bristol.

1916. Brown, William, M.A., M.B., B.Cli.Oxon., D.Sc.Lond., Reader in

Psychology in the University of London (King's College), (King’s
College, Strand, London, W.C. 2); 14, Welbeck Street, W. 1.

1917. Bruce, Alexander Ninian, M.D., D.Sc., F.R.C.P.E., Lecturer on Neuro¬

logy! University of Edinburgh, 8, Ainslie Place, Edinburgh.

1898. Bruce, Lewis C., M.C., M.D., F.R.C.P.Edin., M.P.C., Medical Superinten¬
dent, District Asylum, Druid Park, Murthly, N.B.) ( Co-Editor of
Journal 1911-1916; Hon. Sec. for Scottish Division , 1901-1907.)

1913. Brunton, George Llewellyn, M.D., Ch.B.Edin., North Riding Asylum,

Clifton, York.

1912. Buchanan, William Murdoch, M.B., Ch.B.Glas., Kirklands Asylum,
Bothwell, Lanarkshire.

1908. Bullmore, Charles Cecil, J.P., L.R.C.P.&S.Ediu,, L.R.F.P.AS.Glas.,

Medical Superintendent, Flower House, Catford, London, S.E. 6.

1912. Burke, J. 1)., M.B., B.Ch., R.U.f,, St. Audry's Hospital, Melton, Suffolk.
1911. Buss, Howard Decimus, B.A., B.Sc. France, M.D.Brux.&Cape, M.R.C.S.,

L.R.C.P., L.M.S.S.A.Lond., Assistant Medical Officer, Fort
Beaufort Asylum, Cape Colony.

1910. Cahir, John P., M.B., B.Ch.R.U.I., 198, Camberwell New Road, Camber¬
well, London, S.E. 5.

1891. Caldecott, Charles, M.B., B.S.Lond., M.R.C.S., L.B.C.P.Lond., Medical
Superintendeut, Royal Earlswood Institution, Redhill, Surrey.

1913. Cameron, John Allan Munro, M.B., Ch.B.Glas. Address uncommuni¬

cated.

1894. Campbell, Alfred Walter, M.D., C.M.Edin., M.P.C., Macquarie Chambers,
183, Macquarie Street, Sydney, New South Wales.

1909. Campbell. Donald Graham, M.B., C.M.Edin., “ Auchinellan,” 12, Reid-

haven Street, Elgin.

1914. Campbell, Finlay Stewart, M.D., C.M.Glas., Deputy Director of Medical

Services, Ministry of National Service, Ayr, Scotland.

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x Members of the Association.

1897. Campbell, Robert Brown, M.D., C.M., F.R.C.P.E., Stirling District
Asylum, Larbert. ( Secretary for Scottish Division from 1910.)

1905. Carre, Henry, L.R.C.P.&S.Irel., Woodilee Asylum, Lenzie, Glasgow.

1891. Carswell, John, L.R.C.P.Edin., L.R.F.P.&S.Glasg., 43, Moray Place,

Edinburgh ; Commissioner-General, Board of Control, Scotland.
1874. Cassidy, D. M., M.D., C.M.McGiU Coll., Montreal, D.Sc. (Public
Health) F.R.C.S.Edin., Medical Superintendent, County Asylum,
Lancaster.

1888. Chambers, James, M.A., M.D.R.U.I., M.P.C., The Priory, Roehampton,
London, S.W. 15. (Co-Editor of Journal 1905-1914, Assistant
Editor 1900-06.) (Pbbsidbnt, 1913-14.) (Treasurer since
1917.)

1911. Chambers, Walter Duncanon, M.A., M.D., Ch.B.Edin., M.P.C., Deputy
Commissioner, 1, Cr&iglea Place, Edinburgh.

1865. Chapman, Thomas Algernon, M.D.Glns., L.R.C.S.Edin., F.R.S., F.Z.S.,
Betula, Ileigate.

1915. Cheyne, Alfred William Harper, M.B., Ch.B.Aber., Assistant Medical
Officer, Iioyal Asylum, Aberdeen.

1917. Chisholm, Percy, L.lt.C.P. & S.Edin., Assistant Medical Officer, Stirling
District Asylum, Larbert.

1907. Chislett, Charles ,G. A., M.B., Ch.B.Glasg., Medical Superintendent,
Stoneyetts, Chryston, Lanark.

1880. Christie, J. W. Stirling, L.R.C.P.&S.Edin., 21, St. Matthew’s Gardens,
St. Leonards-on-Sea.

1878. Clapham, Win. Crochley S., M.D., F.R.C.P.Ed., M.R.C.S.Eng., F.S.S., The
Five Gables, Mayfield, Sussex. (Hon. Sec . N. and M. Division ,
1897—1901.)

1907. Clarke, Geoffrey, M.D.Lond., Senior Assistant Medical Officer, London
County Mental Hospital, Banstead, Sutton, Surrey.

1910. Clarke, James Kilian P., M.B., B.Ch.R.U.I., D.P.H., High Street,
Oakham.

1907. Clarkson, Robert Durward, B.Sc., M.D., C.M.Edin., F.R.C.P.Edin.

(Medical Officer, Scottish National Institute for the Education of
Imbecile Children), The Park, Larbert, Stirling.

1892. Cole, Robert Henry, M.D.Lond., F.R.C.P.Lond., 26, Upper Berkeley

Street, London, W. 1. (Secretary of Parliamentary Committee
since 1912.)

1900. Cole, Sydney John, M.A., M.D., B.Ch.Oxon., Medical Superintendent,
Wilts County Asylum, Devizes.

1906. Collier, Walter Edgar, M.R.C.S., L.R.C.P.Lond., Assistant Medical

Officer, Kent County Asylum, Maidstone.

1903. Collins, Michael Abdy, O.H.E., M.D.,B.S.Lond.,M.R.C.S., L.R.C.P.Lond.,
Charthum Down, near Canterbury, Kent. (Hon. General Secretary,
1912-18.)

1910. Conlon, Thomas Peter, L.R-C.P.&S.Irel., Resident Medical Superin¬
tendent, District Asylum, Monaghan.

1914. Connolly, Victor Lindley, M.C. , M.B., B.Ch.Belfast, Assistant Medical
Officer, Long Grove Mental Hospital, Epsom, Surrey.

1910. Coombes, Pcrcival Charles, M.R.C.S., L.R.C.P.Lond., Medical Superin¬
tendent, Surrey County Asylum, Netherne.

1905. Cooper, K. D., L.R.C.P.&S.Edin., L.R.F.P.&S.Glas., c/o Leopold & Co.
Apollo, Bunder, Bombay.

1903. Cormac, Harry Dove, M.B., B.S.Madras, Medical Superintendent,
Cheshire County Asylum, Macclesfield.

1891. Corner, Harry, M.D.Lond., M.R.C.S., L.R.C.P.Lond., M.P.C., 37, Harley
Street, London, W. 1.

1917. Costello, Christopher, M.B., B.Ch., N.U.I., Assistant Medical Officer,
Portrane Asylum, Ireland.

1897. Cotton, William, M.A.,M.D.Edin., D.P.H.Cantab.,M.P.C.,231,Gloucester
Road, Bishopston, Bristol.

1910. Couplaud, William Henry, L.R.C.S.&P.Edin., Medical Superintendent,
Royal Albert Institution, Albert House, Haverbreaks, Lancaster.

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1913. Coart, E. Percy, M.R.C.S., L.R.C.P.Lond,, Severalls Asylum, Colchester.
1893. Cowen, Thomas Philip, M.D., B.S. M.R.C.S., L.R.C.P.Lond., Medical

Superintendent, County Asylum, Rainhill, Lancashire.

1911. Cox, Donald Maxwell, M.R.C.S., L.R.C.P.Lond., 2, Royal Park, Clifton,
Bristol.

1918. Cox, Francis Michael, M.D., F.R.C.P.Lond., Physician, St. Vincent’s

Hospital, Dublin; Lord Chancellor’s Consulting Visitor in Lunacy
for County and City of Dublin; 26, Merrion Square, Dublin.

1893. Craig, Maurice, C.B.F., M.A., M.D.,B.C.Cantab., F.R.C.P.Lond.,M.P.C.,

87, Harley Street, London, W. 1. ( Hon . Secretary of Educational
Committee , 1905-8; Chairman of Educational Committee since
1912.)

1897. Cribb, Harry Gifford, M.R.C.S., L.R.C.P.Lond., Medical Superintendent,
Winterton Asylum, Ferryhill, Durham.

1911. Crichlow, Charles Adolphus, M.B., Ch.B.Glas. Roxburgh District
Asylum, Melrose.

1917. Crocket, James, M.D.Edin., D.P.H., Medical Superintendent, Colony of
Mercy for Epileptics, Consumption Sanatoria of Scotland, Craigielea,
Bridge of Weir.

1914. Crookshank, Francis Graham, M.D., M.R.C.P.Lond., 15, Harley Street,

London, W. 1.

1904. Cross, Harold Robert, L.S.A.Lond., F.R.G.S., Storthes Hall Asylum,

Kirkburton, near Huddersfield.

1915. Crosthwaite, Frederick Douglas, M.B., Ch.B.Edin., D.P.H.Cantab.,

Assistant Physician, Pretoria Mental Hospital, South Africa.

1914. Cruickshank, J., M.D., Ch.B.Glas., Pathologist, Crichton Royal Hospital,
Dumfries.

1919. Cuthbert, James Harvey, M.B., Ch.B.Edin., Senior Assistant Medica

Officer, West Ham Mental Hospital, Goodmayes, Essex.

1907. Daniel, Alfred Wilson, B.A., M.D., B.C.Cantab., M.R.C.S., L.R.C.P.Lond,,

Medical Superintendent, London County Mental Hospital, Hanwell,
London, W. 7. ( Secretary of Educational Committee.)

1896. Davidson, Andrew, M.D., C.M.Aber., M.P.C., Wyoming, Macquarie
Street, Sydney, N.S.W.

1914. Davies, Laura Katherine, M.B., Ch.B.Edin., Pathologist and Assistant

Medical Officer, Edinburgh City Asylum, Bangour, Declimont,
Linlithgowshire.

1891. Davis, Arthur N., L.R.C.P.&S.Edin., Medical Superintendent, County
Asylum, Exminster, Devon.

1894. Dawson, William R., O.B.E. , B.A.,M.D.,B.Ch.Dubl., F.R.C.P.I.,D.P.H„

Inspector of Lunatics in Ireland, 7, Ailesbury Road, Dublin. (Ron.
Sec . to Irish Division, 1902-11; PRESIDENT, 1911-12; Co-Editor
of the Journal since 1920.)

1901. De Steiger, Ad&le, M.D.Lond., County Asylum, Breutwood, Essex.

1905. Devine, Henry, M.D., B.S., F.R.C.P.Lond,, M.R.C.S.Eng.,

M.P.C., Medical Superintendent, The Asylum, Milton, Portsmouth.
(Co-Editor of the Journal since 1920; Assistant Editor 1916-20.)

1904. Devon, James, L.R.C.P. k S.Edin., 11, Rutland Square, Edinburgh.

1903. Dickson, Thomas Graeme, L.R.C.P. <fc S.Edin., The Merse Cottage,

Bakewell, Derbyshire.

1915. Dillon, Frederick, M.B., Ch.B.Edin., Assistant Medical Officer,

Northumberland House, Green Lanes, Finsbury Park, London, N. 4.
1909. Dillon, Kathleen, L.R.C.P.&S.I., Assistant Medical Officer, District
Asylum, Mullingar.

1905. Dixon, J. Francis, M.A., M.D., B.Ch.Dubl., M.P.C., Medical Super-

intendent. Borough Mental Hospital, Huroberstone, Leicester.

1879. Dodds, William J., M.D., C.M., D Sc.Edin., 15, Marina Road, Prestwick,
Ayrshire.

1908. Donald, Robert, M.D., Ch.B.Glas., 3, Gilmour Street, Paisley.

1889. Donaldson, William Ireland, B.A., M.D., B.Ch.Dubl., 2, Abbeylands,
Killiney, Co. Dublin.

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xii Members of the Association .

1892. Douelau, John O’Conor, L.R.C.P.&S.I., M.P.C., St. Dyinphna’s, North
Circular Road, Dublin (Med. Supt., Richmond Asylum,
Dublin).

1890. Douglas, William, M.D.R.U.I., M.U.C.S.Eng., F.R.G.S., Brandfold,

Goudburst, Kent.

1905. Dove, Augustus Charles, M.D., B.S.Durh., M.R.C.S.Eng., " Brightside,”

Crouch End Hill, London, N. 2.

1910. Downey, Michael Henry, M.B., Ch.B.Melb., L.R.C.P. & S.Edin.,

L.R.F.P. A S. Glasg., Medical Superintendent, Parkside Asylum,
Adelaide, South Australia.

1919. Drake-Brockman, Henry George, M.R.C.S., L.R.C.P.Lond., The Mental
Hospital, Middlesbrough.

1916. Drummond, William Blackley, M.B., C.M.Edin., F.U.C.P.Edin., Medical

Superintendent, Baldovan Institution, Dundee.

1907. Dryden, A. Mitchell, M.B., Ch.B.Edin., Senior A.M.O., Woodilee Mental
Hospital, Lenzie.

1902. Dudgeon, Herbert Wm., M.D., B.S.Durh., M.R.C.S., L.R.C.P.Lond.,

Medical Superintendent, Khanka Government Asylum, Egypt.
1899. Dudley, Francis, L.R.C.P.AS.I., Senior Assistant Medical Officer,
County Asylum, Bodmin, Cornwall.

1915. Duff, Thomas, L.R.C.P. A S.Edin., L.R.F.P.AS.Glasg., Collington Rise,
Bexhill-on-Sea.

1917. Dunn, Edwin Lindsay, M.B., B.Ch.Dub., Medical Superintendent, Berks

County Asylum, WalliDgford, Berks.

1903. Dunston, John Thomas, M.D., B.S.Lond., Medical Superintendent, West

Koppies Mental Hospital, Pretoria, South Africa.

1911. Dykes, Percy Armstrong, M.R.C.S., L.R.C.P.Lond., c/o Messrs. Holt

and Co., 3, Whitehall Place, London, S.W. 1.

1899. Eades, Albert I., L.R.C.P. & S.I., Medical Superintendent, North Riding
Asylum, Clifton, Yorks.

1906. Eager, Richard, M.D., Ch.B.Aber., M.P.C., Assistant Medical

Officer, The Devon Mental Hospital, Exminster.

1891. Earls, James Henry, M.D., M.Ch.R.U.I., D.P.H., L.S.A.Lond., M.P.C.,

Barrister-at-Law, Fenstanton, Christchurch Road, Streatham Hill,
London, S.W. 2.

1907. East, Wm. Norwood, M.D.Loud., M.R.C.S., L.R.C.P.Lond., M.P.C.,

H.M. Prison, Manchester; 17, Walton Park, Liverpool.

1895. Easterbrook, Charles C., M.A..M.D., F.R.C.P.Ed., M.P.C., J.P., Physician
Superintendent, Crichton Royal Institution, Dumfries.

1914. Eder, M. D., B.Sc.Loud., M.R.C.S., L.R.C.P.Lond. (Medical Officer,
Deptford School Clinic), 37, Welbeck Street, London, W. 1.

1895. Edgerley, Samuel, M.A., M.D., C.M.Edin., M.P.C., Medical Superintend
dent, West Riding Asylum, Menston, nr. Leeds.

1897. Edwards, Francis Heury, M.D.Brux., M.R.C.P.Lond., M.R.C.S.Eng.,

Medical Superintendent, Camberwell House, London, S.E.6.

1919. Eggleston, Henry, M.B., B.8.Durb., Allerton Tower Home of Recovery,
Wool ton, Liverpool.

1901. Elgee, Samuel Charles, O.B.E. , L.R.C.P.AS.I., Medical Superintendent,
Cane Hill Mental Hospital, Coulsdon, Surrey.

1898. Elkins, Frank Ashby, M.D., C.M.Edin., M.P.C., Medical Superintendent,

Metropolitan Asylum, Leavesden, Herts.

1912. Ellerton, John Frederiok Heise, M.D.Brux., M.R.C.S.Eng., L.R.C.P.

Edin., Rotherwood, Leamington Spa.

1917. Ellis, Vincent C., M.B., B.Ch.Dub., Assistant Medical Officer, Richmond
Asylum, Grangegorman, Dublin.

1908. Ellison, Arthur, M.R.C.S., L.R.C.P.Eng., Deputy Medical Officer, H.M.

Prison, Leeds; 10, Sholebroke Avenue, Leeds.

1899. Ellison, F. C., B.A., M.D., B.Ch.Dub., Resident Medical Superintendent,

District Asylum, Castlebar.

1911. Etnslie, Isabella Galloway, M.D., Ch.B.Edin., West House, Royal Asylum,
Morningside, Edinburgh.

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Members of the Association . xiii

1911. English, Ada, M.B., B.Ch.R.U.I., Assistant Medical Officer, District
Asylum, Ballinasloe.

1901. Erskine, Wm. J. A., M.D., C.M.Edin., Medical Superintendent, County

Asylum, Whitecroft, Newport, I. of W.

1896. Enrich, Frederick Wilhelm, M.D., C.M.Edin., 8, Mornington Villas,
Maningham Lane, Bradford.

1894. Eustace, Henry Marcus, B.A., M.D., B.Ch.Dubl., M.P.C., Medical
Superintendent, Hampstead and Highfield Private Asylum,
Glasneviu, Dublin.

1909. Eustace, William Neilson, L.R.C.S. A P.Trel., Lisronagh, Glasnevin,
Co. Dublin.

1918. Evans, A. Edward, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond., D.P.H.

Liverp., Inspector, Board of Control, 3, Rotherwiek Court, Holders
Green, Loudon, N.W. 4.

1909. Evans, George, M.B.Lond., Senior Assistant Medical Officer, Severalls
Asylum, Colchester.

1918. Evans, Tudor Benson, M.B., Ch.B.Liverp., 247, Boundary Street, Liver*
pool.

1891. Ewan, John Alfred, M.A. St. And., M.D., C.M.Edin., M.P.C., Greylees,
Sleaford, Lines.

1914. Ewing, Cecil Wilmot, L.R.C.P. A S.I. (Second Assistant Medical Officer,
Chartham Asylum, near Canterbury), Lord Derby War Hospital,
Warrington.

1907. Exley, John, L.R.C.P.I., M.R.C.S.Eng., Medical Officer, H.M. Prison;
Grove House, New Wortley, Leeds.

1894. Farquharson, William F., M.D., C.M.Edin., M.P.C., Medical Superin¬
tendent, Counties Asylum, Garlands, Carlisle.

1907. Farries, John Stothart, L.R.C.P.AS.Edin., L.R.F.P.AS.Glas., The Cottage,

Hethersgill, Carlisle.

1908. Fennell, Charles Henry, M.A., M.D.Oxon, M.R.C.P.Lond., Reform Club,

Pall Mall, London, S.W. 1.

1908. Fenton, Henry Felix, M.B., Cb.B.Edin., Assistant Medical Officer,
County and City Asylum, Powick, Worcester.

1907. Ferguson, J. J. Harrow er, M.B., Cb.B.Edin., Senior Assistant Medical

Officer, Fife and Kinross Asylum, Cupar, Fife.

1906. Fielding, Saville James, M.B., B.S.Durh., Medical Superintendent,
Bethel Hospital, Norwich.

1878. Finch, John E. M., M.A., M.D.Cantab., M.R.C.S.Eng., L.S.A.Lond.,
Holmdale, Stoneygate, Leicester.

1889. Finlay, David, M.D., C.M.Glasg., Medical Superintendent, County
Asylum, Bridgend, Glamorgan.

1906. Firth, Arthur Harcns, M.A., M.D., B.Ch.Edin., Deputy Medical Super¬
intendent, Barnsley Hall, Bromsgrove, Worcestershire.

1908. Fitzgerald, Alexis, L.R.C.P. A S.I., Medical Superintendent, District

Asylum, Waterford.

1888. Fitz-Gerald, Gerald C., B.A., M.D., B.C.Cantab., M.P.C., 7, Mermaid
Street, Rye, Sussex.

1908. Fitsgeruld, James Francis, L.R.C.P.AS.Irel., Assistant Medical Officer,
District Asylum, Clonmel, co. Tipperary, Ireland.

1904. Fleming, Wilfrid Louis Remi, M.R.C.S., L.R.C.P.Lond., Suffolk House,
Pirbright, Surrey.

1894. Fleury, Eleonora Lilian, M.D., B.Ch.R.U.I., Assistant Medical Officer,
Richmond Asylum, Dublin.

1908. Flynn, Thos. Aloysius, L.R.C.P.AS.I., County Asylum, Thorpe, Norwich.

1902. Forde, Michael J., M.D., B.Ch.R.U.I., Assistant Medical Officer, Rich¬

mond Asylum, Dublin.

1911. Forrester, Archibald Thomas William, M.D., B.S., M.R.C.S., L.R.C.P.

Loud., Senior Assistant Medical Officer, Leicester and Rutland
Counties Asylum, Narborough.

1916. Forsyth, Charles Wesley, M.B., M.R.C.S., L.R.C.P.Lond., Assistant
Medical Officer, Kesteven County Asylum, 81eaford, Lines.

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Digitized by

xiy Members of the Association.

1913. Forward, Ernest Lionel, M.R.C.S., L.R.C.P.Lond., Wharncliffe War
Hospital, Sheffield.

1918. Fothergill, Claude Francis, B.A., M.B., B.C.Cantab., M.R.C.S., L.R.C.P.

Lond.; Hensol, Chorley Wood, Herts.

1912. Fox, Charles J., M.R.C.S., L.R.C.P.Lond., The Moat House, Alnechurch,
Birmingham.

1881. Fraser, Donald, M.D., C.M.Glasg., F.R.F.P. & S.Glas., 13, Royal Terrace
West, Glasgow.

1919. Fraser, Kate, B.Sc., M.D., D.P.H., Deputy Commissioner, General Board

of Control, Scotland ; 13, Royal Terrace West, Glasgow.

1901. French, Louis Alexander, M.R.C.S., L.R.C.P.Lond., “ Locksley,”

Willingdon, Eastbourne.

1902. Fuller, Lawrence Otway, M.R.C.S.Eng., L.R.C.P.Lond., Medical Super¬

intendent, Three Counties’ Asylum, Arlesey, Beds.

1914. Gage, John Munro, L.R.C.P.&S.I., M.P.C., Royal Earlswood Institution,
Red hi 11, Surrey.

1906. Gane, Edward Palmer Steward, M.D.Durh., M.R.C.S., L.R.C.P.Lond.,
The Coppice, Nottingham.

1912. Garry, John William, M.B., B.Ch., N.U.I., Assistant Medical Officer,
Ennis District Asylum, Ireland.

1912. Gavin, Lawrence, M.B., Ch.B.Edin,, L.R.C.P.&S.Edin., L.R.F.P.&S.
Glasg., Superintendent, Mullingar District Asylum, Ireland.

1896. Geddes, John W., M.B., C.M.Edin., Medical Superintendent, Mental

Hospital, Middlesbrough, Yorks.

1892. Gemmel, James Francis, M.B.Glasg., Medical Superintendent, County
Asylum, Whittingham, Preston.

1919. Gifford, John, B.A., M.B., Ch.B., Senior Assistant Medical Officer,
Derby County Asylum, Mickleover.

1899. Gilfillan, Samuel James, M.A., M.B., C.M.Edin., Medical Superintendent,
London County Mental Hospital, Colney Hatch, Loudon, N. 11.
1912. Gill, Eustace Stanley Hayes, M.B., Ch.B.Liverp., Shaftesbury House,
Formby, Liverpool.

1889. Gill, Stanley A., B.A.Dubl., M.D.Durh., M.R.C.P.Lond., M.R.C.S.Eng.,
Shaftesbury House, Formby, Liverpool.

1904. Gillespie, Daniel, M.C., M.D., B.Ch.R.U.I., Dipl. Psych., Wadsley Asylum,

near Sheffield.

1897. Gilmour, John Rutherford, M.B., C.M., F.R.C.P.Edin., M.P.C., Medical

Superintendent, West Riding Asylum, Scalebor Park, Burley-in-
Wliarfedale, Yorks.

1906. Gilmour, Richard Withers, M.B., B.S.Durh., M.R.C.S., L.R.C.P.Lond.,
Homewood House, West Meon, Hants.

1878. Glendinning, James, M.D.Glasg., L.R.C.S.Edin. Hill Crest, Lansdown
Road, Abergavenny.

1897. Good, Thomas Saxty, M.R.C.S.Eng., L.R.C.P.Lond., Medical Superin¬
tendent, County Asylum, Littlemore, Oxford.

1889. Goodall, Edwin, C.B.J2., M.D., B.S., F.R.C.P.Lond., M.P.C., Medical
Superintendent, City Mental Hospital, Cardiff.

1918. Goodfellow, Thomas Ashton, M.D.Lond., B.Sc., M.R.C.S., L.R.C.P.,
60, Palatine Road, West Didsbury, Manchester.

1899. Gordon, James Leslie, M.D., C.M.Aberd. (Medical Superintendent,
Fountain Temporary Asylum, Tooting Grove, Tooting Graveney,
London, S.W. 17).

1905. Gordon-Munn, John Gordon, M.D.Edin., F.R.S.E., Heigham Hall,

Norwich.

1901. Gostwyck, C. H. G., M.B., Ch.B., F.R.C.P.Edin., M.P.C., Dipl. Psych.,
Stirling District Asylum, Larbert.

1912. Graham, Gilbert Malise, M.B., Ch.B.Edin., R.N., H.M.S. “ Emperor of
India.”

1914. Graham, Norman Bell, M.C., B.A., R.U.I., M.B., B.Ch.Belfast, Assistant
Medical Officer, District Asylum, Belfast.

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Members of the Association.

1894. Graham, Samuel, L.R.C.P.Lond., Resident Medical Superintendent,
District Asylum, Antrim.

1918. Graham, Samuel John, L.R.C.P., L.R.C.S.Edin., L.R.F.P.S.Glasg.,
Resident Medical Superintendent, Villa Colony Asylum, Pnrdys-
burn, Belfast.

1908. Graham, William S., M.B., B.Ch.R.U.I., Assistant Medical Officer,

Somerset and Bath Asylum, near Taunton.

1916. Graves, T. Chivers, M.B., B.S., B.Sc.Lond., F.R.C.S.Eng., Medical Super¬
intendent, The Asylum, Rubery Hill, nr. Birmingham.

1916. Gray, Cyril, L.R.C.P.&.S.Edin., Gateshead Borough Asylum, Stannington,
Newcaatle-on-Tyne.

1909. Greene, Thomas Adrian, L.R.C.S.&P.Irel., J.P., Medical Superintendent,

District Asylum, Carlow.

1886. Greenlees, T. Duncan, M.D., C.M.Edin., F.R.S.E., Rostrevor, Kirtleton
Avenue, Weymouth.

1912. Greeson, Clarence Edward, M.D., Ch.B.Aherd., c/o Messrs. Holt A Co.,
3, Whitehall Place, London, S.W. 1.

1915. Grigsby, Hamilton Marie, L.R.C.P.&S.Edin., 79, Victoria Road North,

Southsea.

1901. Grills, Galbraith Hamilton, M.D., B.Ch.R.U.I., Dipl. Psych., Medical
Superintendent, County Asylum, Chester.

1916. Grimbly, Alan F., B.A., M.A., M.D.Trin.Coll.Dublin, B.Ch., B.A.O.,

L.M.Rot.Dub. (Assistant Medical Officer, St. Edmondsbury, Lucan,
Ireland); R,N. Hospital, Chatham.

1900. Grove, Ernest George, M.R.C.S., L.R.C.P.Lond., Bootham Park, York.
1894. Gwynn, Charles Henry, M.D., C.M.Edin., M.R.C.S.Eng., co-Licensee,
St. Mary's House, Whitchurch, Salop.

1894. Halsted, Harold Cecil, M.D.Durh., M.R.C.S., L.R.C.P.Lond., Manor
Road, Selsey, Sussex.

1901. Harding, William, C.3.E., M.D.Edin., M.R.C.P.Lond., Medical Superin¬
tendent, Northampton County Asylum, Berry Wood, Northampton,

1899. Harmer, W. A., L.S.A., Resident Superintendent and Licensee, Redlands

Private Asylum, Tonbridge, Kent.

1904. Harper-Smith, George Hastie, B.A.Cantab., M.R.C.S., L.R.C.P.Lond.,

(Senior Assistant Medical Officer, Brighton County Borough
Asylum, Haywards Heath), May Cottage, Loughton, Essex.

1898. Harris-Liston,L.,M.D.Brux.,M.R.C.S., L.R.C.P.Lond., L.S. A., Middleton
Hall, Middleton St. George, Co. Durham.

1905. Hart, Bernard, M.D.Lond., M.R.C.S.Eng., 81, Wimpole Street, London,

W. 1, and Northumberland House, Finsbury Park, London, N. 4.
1886. Harvey, Bagenal Crosbie, L.R.C.P.&S.Edin., L.A.H.Dubl., Resident
Medical Superintendent, District Asylum, Clonmel, Ireland.

1892. Haslett, William John H., M.R.C.S., L.R.C.P.Lond., M.P.C., Resident
Medical Superintendent, Halliford House, Sunbury-on-Thamee.
1891. Havelock, John G., M.D., C.M.Edin., Cluny, Swanage, Dorset.

1890. Hay, J. F. S., M.B., C.M.Aberd., Inspector-General of Asylums for New
Zealand, Government Buildings, Wellington, New Zealand.

1900. Haynes, Horace E. t M.R.C.S.Eng., L.S.A., J.P., Littleton Hall, Brent¬

wood, Essex.

1911. Heffernan, P., B.A., M.B., B.Ch.C.U.I.

1916. Henderson, David Kennedy, M.D.Edin., Senior Assistant Physician,
Royal Asylum, Gartnavel, Glasgow.

1905. Henderson, George, M.A., M.B., Ch.B.Edin., 25, Commercial Road,
Peckham, London, S.E. 15.

1877. Hetherington, Charles E., B.A., M.B., M.Ch.Dubl., Medical Superin¬
tendent, District Asylum, Londonderry, Ireland.

1877. Hewson, R. W., L.R.C.P.&S.Edin., Medical Superintendent, Coton Hill,
Stafford.

1914. Hewson, R. W. Dale, L.R.C.P.&S.Edin., L.R.F.P.&S.Glas., Coton Hill
Hospital, Stafford.

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xvi Members of the Association .

1912. Higson, William Davis, M.B., Ch.B.Liverp., D.P.H., Deputy Medical
Officer, H.M. Prison, Brixton; 7, Clovelly Gardens, Upper Tulse
Hill, London, S.W. 2.

1882. Hill, H. Gardiner, M.R.C.S.Eng., L.S.A., Pentillie, Leopold Road,
Wimbledon Park, London, S.W. 19.

1914. Hills, Harold William, B.S., M.B., B.Sc.Lond., M.R.C.S., L.R.C.P.Lond.;
Lord Derby War Hospital, Warrington.

1907. Hine, T. Guy Macaulay, M.A., M.D., B.C.Cantab., 87, Hertford Street,

Mayfair, London, W. 1. _

1909. Hodgson, Harold West, M.R.C.S., L.R.C.P.Lond., Assistant Medical
Officer, Several Is Asylum, Colchester.

1908. Hogg, Archibald, M.B., Ch.B.Glas., 54, High Street, Paisley, N.B.

1900. Hollander, Bernard, M.D.Freib., M.R.C.S., L.R.C.P.Lond, 67, Wimpole

Street, London, W. 1.

1903. Hopkins, Charles Leighton, B.A., M.B., B.C.Cantab., Medical Superin¬

tendent, York City Asylum, Fulford, York.

1918. Horton, Wilfred Winnall, M.D.Edin., Medical Superintendent, Wye

House, Buxton.

1894. Hotchkis, Robert D., M.A.Glasg., M.D., B.S.Durb., M.R.C.S., L.R.C.P.

Lond., M.P.C., Renfrew District Asylum, Dykebar, Paisley, N.B.
1912. Hughes, Frank Percival, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond., The
Grove, Pinner, Middlesex.

1900. Hughes, Percy T., M.B., C.M.Edin., D.P.H., Medical Superintendent,
Worcestershire County Asylum, Barnesley Hall, Bromsgrove.

1904. Hughes, William Stanley, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond.,

Medical Superintendent, Shropshire County Asylum, Bicton Heath,
Shrewsbury.

1897. Hunter, David, M.A., M.B., B.C.Cantab., L.S.A., Medical Superintendent,
The Coppice, Nottingham. ( Secretary for S.K. Division, 1910-1918.)

1909. Hunter, Douglas William, M.B., Ch.B.Glasg., Assistant Medical Officer,

10, Hall field Road, Bradford.

1912. Hunter, George Yeates Cobb, M.R.C.S., L.R.C.P.Lond., M.P.C.,

c/o Messrs. Grindlay A Co., 64, Parliament Street, London,
S.W.l.

1904. Hunter, Percy Douglas, M.R.C.S., L.R.C.P.Lond., Three Counties

Asylum, Arlesey, Beds.

1888. Hyslop, Theo. B., M.D., C.M.Edin., M.R.C.P.E., L.R.C.S.E., F.R.S.E.,
M.P.C., 6, Portland Place, London, W. 1.

1916. Ingall, Frank Ernest, F.R.C.S.Eng., L.R.C.P.Lond., D.P.H., Tue Brook
Villa, Liverpool.

1908. Inglis, J. P. Park, M.B., Ch.B.Edin., Assistant Medical Officer,
Caterham Asylum, Caterham, Surrey.

1906. Irwin, Peter Joseph, L.R.C.P.&S.I., Assistant Medical Officer, District
Asylum, Limerick.

1914. James, George William Blomfield, M.B., B.S.Lond., The Lawn,
Hillingdon, Uxbridge.

1908. Jeffrey, Geo. Rutherford, M.D., Ch.B.Glas., F.R.C.P.E., M.P.C.,
Medical Superintendent, Bootham Park, York.

1893. Johnstou, Gerald Herbert, L.R.C.P.AS.Edin., L.R.F.P.AS.Glas., Brooke
House, Upper Clapton, London, N. 5.

1919. Johnston, Millicent Hamilton,' B.A., M.B., B.Cb.Dub., Assistant Medical

Officer, Brentwood Mental Hospital, Essex.

1905. Johnston,Thomas Leonard, L.lLC.P.AS.Edin., L.R.F.P&.S.Glas.,Medical

Superintendent, Bracebridge Asylum, Lincoln.

1912. Johnstone, Emma May, L.R.C.P. & S.Edin., L.R.F.P.&S.Glas., M.P.C.,
Dipl. Psych., Holloway Sanatorium, Virginia Water, Surrey.

1878. Johnstone, J. Carlyle, M.D., C.M.Glas., Melrose, Roxburgh.

1903. Johnstone, Thomas, M.D., C.M.Edin., M.R.C.P.Lond., Annandale,
Harrogate.

1880. Jones, D. Johnston, M.D., C.M.Edin.

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1879, Kay, Walter S., M.D., C.M.Edin., M.R.C.S.Eng., The Grove, Starbech,
Harrogate.

1886. Keay, John, C.R.2F., M.D., C.M.Glasg., F.R.C.P.Edin., Medical Super¬
intendent, Bangonr Village, Uphall, Linlithgowshire. ( President,
1918.)

1909. Keith, William Brooks, M.B., Ch.B.Aberd., M.P.C., 81st Field Ambulance,
27th Division.

1908. Kelly, Richard, M.D., B.Ch.Dub., Assistant Medical Officer, Storthes
Hall Asylum, Kirkburton, near Huddersfield.

1907. Keene, George Henry, M.D., 14, Palmerston Park, Dublin.

1899. Kennedy, Hugh T. J., L.R.C.P.&S.L, Assistant Medical Officer, District
Asylum, Enniscorthy, Co. Wexford.

1897. Kerr, Hugh, M.A., M.D.Glasg., Medical Superintendent, Bucks County

Asylum, Stone, Aylesbury, Bucks.

1902. Kerr, Neil Thomson, M.B., C.M.Ed., Medical Superintendent, Lanark

District Asylum, Hartwood, Shotts, N.B.

1898. Kershaw, Herbert Warren, M.R.C.S.Eng., L.R.C.P.Lond., 1, Stanhope

Road, Darlington.

1897. Kidd, Harold Andrew, C.JB.JS., M.R.C.S.Eng., L.R.C.P.Lond., Medical
Superintendent, West Sussex Mental Hospital, Chichester.

1916. Kilgarriff, Joseph O’Loughlin, A.B., M.B., B.Ch., B.A.O.Univ.,
Dublin, Assistant Medical Officer, County Asylum, Prestwich,
Lancs.

1903. King, Frank Raymond, B.A.Cantab., M.R.C.S.Eng., L.R.C.P.Lond.,

Medical Superintendent, Peckham House, Peckham, London,
S.E.

1902. King-Turner, A. C., M.B., C.M.Edin., The Retreat, Fair ford, Gloucester¬

shire.

1915. Kirwan, Richard R., M.B., B.Ch. R.U.I., Assistant Medical Officer,
West Riding Asylum, Menston, Leeds.

1915. Kitson, Frederick Hubert, M.B., Ch.B.Leeds, Assistant Medical Officer,
West Riding Asylum, Wakefield.

1919. Knight, Mary Reid, M.A., M.B., Ch.B., Assistant Medical Officer,
Paisley District Asylum, Riccartsbar, Paisley, Scotland.

1903. Kough, Edward Fitzadam, B.A., M.B., B.Ch.Dubl., Senior Assistant

Medical Officer, County Asylum, Gloucester.

1898. Labey, Julius, M.R.C.S., L.R.C.P., L.S.A.Lond., Medical Superin¬
tendent, Public Asylum, Jersey.

1902. Langdon-Down, Peroival L., M.A., M.B., B.C.Cautab., Normansfield,
Hampton Wick, Middlesex.

1896. Langdon-Down, Reginald L., M.A., M.B., B.C.Cantab., M.R.C.P.Lond.,
Normansfield, Hampton Wick. %

1919. Langton, Peregrine Stephen Brackenbury, M.R.C.S.Eng., L.R.C.P.Lond.,
M.B., B.S.Lond.., Assistant Medical Officer, York City Asylum,
Fulford, York.

1914. Ladell, R. G. Macdonald, M.B., Ch.B.Viet., The Gables, Killinghall,
Harrogate.

1919. Latham, Oliver, M.B., C.M.Sydney University, Pathologist, Lunacy
Department, Sydney, N.S.W. Permanent Address: Sydney
University, N.S.W.; Temporary Address : No. 1, Australian
Hospital, Sutton Vemey, Warminster.

1909. Laurie, James, M.B., Cli.M.Glasg. ( Visiting Medical Officer, Asylum
and Poorhouse, Greenock, Smithson), Red House, Ardgowan Street,
Greenock, Renfrewshire.

1902. Laval, Evariste, M.B., C.M.Edin., The Guildhall, Westminster, London,
S.W. 1.

1898. Lavers, Norman, M.D.Brux., M.R.C.S., L.R.C.P.Lond. (Medical Super¬
intendent, Bailbrook House, Bath) ; Red Cross Military Hospital,
Moss Side, Maghull, near Liverpool.

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1692. Law lets, George Robert, F.R.C.S.I., L.R.C P.I., Medical Superintendent,
District Asylum, Armagh.

18ft). Lawrence, Alexander, M.A., M.D., C.M.Aberd., 26, Hough Green,
Chester.

1888. Layton, Henry A., M.R.C.S.Eng., L.R.C.P.Edin., 26, Kixnbolton Road,
Bedford.

1916. Leech, H. Brougham, M.D., B.Ch.Dub., Assistant Medical Officer,
County Asylum, Hatton, Warwick.

1909. Leech, John Frederick Wolseley, M.D., B.Ch.Dub., Assistant Medical
Officer, County Asylum, Devizes, Wilts.

1899. Leeper, Richard R., F.R.C.S.I., L.R.C.P.I., M.P.C., Medical Super*
intendent, St. Patrick’s Hospital, Dublin. {Son. Sec. to the Iriih
Division since 1911.)

1883. Legge, Richard J., M.D., R.U.I., L.R.C.S.Edin., “ Comeragh,” Leek*
hampton Road, Cheltenham.

1906. Leggett, William, B.A., M.D., B.Ch.Dubl., Assistant Medical Officer,
Royal Asylum, Sunnyside, Montrose).

1916. Lewis, Edward, L.R.C.P. & S.Edin., L.F.P. & S.Glasg., Cwirlai, Ty*Crosa,
Anglesey.

1914. Lindsay, David George, L.R.C.P.&S.Ediu., Senior Assistant Medical
Officer, Dundee District Asylum, West Green, Dundee.

1908. Littlejohn, Edward Salteine, M.R.C.S., L.R.C.P.Lond., Medical Super¬
intendent, Manor Mental Hospital, Epsom.

1898. Lord, Lt.-Col. John R., C.B.E., M.B., C.M.Edin., Medical Super¬
intendent, Horton Mental Hospital, Epsom. ( Co-Editor oj Journal
since 1911; Assistant Editor of Journal, 1900-11.)

1906. Lowry, James Arthur, M.D., B.Ch., R.U.I., Medical Superintendent,
Surrey County Asylum, Brook wood.

1904. Lyall, C. H. Gibson, L.R.C.P.&S.Edin., Leicester Borough Asylum,
Leicester.

1872. Lyle, Thomas, M.D., C.M.Glasg., 84, Jesmond Road, Newcastle-on*Tyne.

1906. Macarthur, John, M.R.C.S., L.R.C.P.Lond., Assistant Medical Officer,
Colney Hatch Mental Hospital, London, N. 11.

1880 MacBryan, Henry C., L.R.C.P. & S. Edin., Kingsdown House, Box,
Wilts.

1900. McClintock, John, L.R.C. P.&S.Edin., Resident Medical Superintendent,

Grove House, All Stretton, Church Stretton, Salop.

1901. MacDonald, James H., M.B., Ch.B., F.R.F.P.&S.Glasg., Govan District

Asylum, Hawkhead, Paisley, N.B.

1884. MacDonald, P. W., M.D., C.M.Aberd., Grasmere, Spa Road, Weymouth.

{First Son. Sec. S. W. Div. 1894 to 1905.) (Pbesident, 1907-B.)
1911. MacDonald, Ranald, M.D., Ch.B.Edin., London County Mental Hospital,
Bexley, Kent.

1905. MacDonald, William Fraser, M.B., Ch.B.Edin,, M.P.C., 96, Polworth
Terrace, Edinburgh.

1905. McDougall, Alan, M.D., Ch.B.Vict., M.R.C.S., L.R.C.P.Lond., Medical

Director, The David Lewis Colony, Sandle Bridge, near Alderley
Edge, Cheshire.

1911. McDougall, William, M.A., M.B., B.C.Cantab., M.Sc.Vict., 89, Banbury
Road, Oxford.

1906. McDowall, Colin Francis Frederick, M.D., B.S.Durh., Medical Superin¬

tendent, Ticehurst House, Ticehurst, Sussex.

1870. McDowall, Thomas W., M.D.Edin., L.R.C.S.E., “ Burwood,” Wadhurst,
Sussex. (Pbesident, 1897-8.)

1895. Macfarlane, Neil M., M.D., C.M.Aber., Medical Superintendent, Govern¬
ment Hospital, Thlotse Heights, Leribe, Basutoland, South Africa.

1902. McGregor, John, M.B., Ch.B.Edin., Senior Assistant Medical Officer,

County Asylum, Bridgend, Glam.

1917. Mclver, Colin, M.R.C.S., L.R.C.P., c/o Messrs. Grindlay & Co.,

Bombay, India.

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Members of the Association .

1914. Mackay, Magnus Ross, M.D., Ch.B.Edin., Newport Borough Asylum,
Caerleon, Mon.

1917. Mackay, Norman Douglas, M.D., Ch.B., B.Sc., D.P.H.St. And., Dali-
Avon, Aberfeldy, Perthshire.

1916. McKenna, Edward Joseph, M.B., B.Ch., R.U.I., Assistant Medical

Officer, Carlow District Asylum.

1911. Mackenzie, John Cosserat, M.B., Ch.B.Edin., County Mental Hospital,
Burntwood, near Lichfield.

1891. Mackenzie, Henry J., M.B., C.M^Edin., M.P.C., Assistant Medical Officer,
The Retreat, York.

1903. Mackenzie, Theodore Charles, M.D., Ch.B., F.R.C.P.Edin., M.P.C.,

Medical Superintendent, District Asylum, Inverness.

1917. McMaster, Albert Victor, B.A., M.R.C.S.Eng., “ The Mount,” Hills Road,

Cambridge.

1904. Macnamara, Eric Danvers, M.A.Camb., M.D., B.C., F.R.C.P.Lond., 87,

Harley Street, London, W. 1.

1914. Macneill, Celia Mary Colqnlioun, M.B., Ch.B.Edin. (Pathologist, North-
field, Prestonpans); Leith War Hospital, Seafield, Leith.

1910. MacPlmil, Hector Duncan, M.A., M.D., Ch.B.Edin. (Assistant Medical

Officer. City Asylum, Gosforth, Newcastle-on-Tyne.

1882. Macphail, S. Rutherford, M.D., C.M.Edin., Derby Borough Asylum,
Rowditch, Derby.

1901. McRae, G. Douglas, M.D., C.M.Edin., F.R.C.P.Ed., Medical Super¬

intendent, District Asylum, Ayr, N.B. (Co-Editor of the Journal
since 1920; Assistant Editor 1916-20).

1902. Macrae, Kenneth Duncan Cameron, M.B., Ch.B.Edin. (Bangour Village,

Dechmont, Linlithgowshire); M.E.F.

1894. McWilliain, Alexander, M.A., M.B., C.M.Aber., Waterval, Odiham,
Winchfield, Hants.

1916. Manifold, Robert Fenton, M.B., D.Ch.Dub., Senior Assistant Medical
Officer, Denbigh Asylum, North Wales.

1908. Mapother, Edward, M.D., B.S.Lond., F.R.C.S.Eng., Maudsley Hospital,
Denmark Hill, S.E.5.

1908. Marnan, John, B.A., M.B., B.Ch.Dubl., Medical Superintendent, County
Asylum, Gloucester.

1896. Marr, Hamilton C., M.D., C.M., F.R.F.P.&S.Glasg., M.P.C., Commis¬
sioner in Lunacy (10, Succoth Avenue, Edinburgh). (Hon. See.
Scottish Division, 1907-1910).

1913. Marshall, Robert, M.B., Ch.B.Glas. (Assistant Medical Officer, Gartloch

Mental Hospital, Gartcosh, N.B.) ; 19th General Hospital, British
Expeditionary Force.

1905. Marshall, Robert Macnab, M.D., Ch.B.Glasg., M.P.C., 2, Clifton Place,

Glasgow.

1908. Martin, Henry Cooke, M.B., Ch.B.Edin., Assistant Medical Officer,
Newport Borough Asylum, Caerleon.

1896. Martin, James Charles, L.R.C.S. AP.I., J.P., Assistant Medical Officer,
District Asylum, Letterkenny, Donegal.

1908. Martin, James Ernest, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond.

Assistant Medical Officer, Long Grove Mental Hospital, Epsom,
Surrey.

1907. Martin, Mary Edith, L.R.C.P.AS,Edin., L.R.F.P.AS.Glas., L.S.A.Lond.,
M.P.C.Lond., Bailbrook House, Bath.

1914. Martin, Samuel Edgar, M.B., B.Ch.Edin., Barrister-at-Law (Senior

Assistant Medical Officer, St. Andrew's Hospital, Northampton) ;
British Mediterranean Expeditionary Force.

1911. Martin, William Lewis, M.A., M.B., C.M., B.Sc., D.P.H.Edin., M.P.C.,

Dipl. Psych. ( Certifying Physician in Lunacy, Edinburgh Parish
Council ), 56, Bruntsfield Place, Edinburgh.

1911. Mathieson, James Moir, M.B., Ch.B.Aber., Assistant Medical Officer,
Wadsley Asylum, Sheffield; 172, Whitham Road, Broomhill, Sheffield.
1904. May, George Francis, M.D., C.M.McGill, L.S.A., Winterton Asylum,
Ferryhill, Durham.

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1912. Melville, William Spence, M.B., Ch.B.Glaa., Woodilee Mental Hospital,
Lenzie, Glasgow.

1890. Meniies, William P., M.D.,B.Sc.Edin., M.R.C.P.Lond., Medical Superin¬
tendent, Stafford County Asylum, Cheddleton, near Leek.
(Pbesidknt-Elbct.)

1877. Merson, John, M.A., M.D., C.M.Aber., Medical Superintendent, Borough
Asylum, Hull.

1893. Middlemass, James, M.A., M.D., C.M., B.Sc.Edin., F.R.C.P., M.P.C.,
Medical Superintendent, Borough Asylum, Ryhope, Sunderland.

1910. Middlemiss, James Ernest, M.R.C.S.Eng., L.R.C.P.Lond.; 131, North

Street, Leeds.

1883. Miles, George E., M.R.C.S., L.R.C.P.Lond., D Block, Royal Victoria
Hospital, Netley, Hants; British Empire Club, St. James' Square,
London, S.W. 1.

1887. Miller, Alfred, M.B., B.Ch.Dubl., Medical Superintendent, Hatton
Asylum, Warwick. (Registrar since 1902.)

1912. Miller, Richard, M.B., B.Ch.Dubl., Stock, Ingatestone.

1893. Mills, John, M.B., B.Ch., Dipl. Ment. Dis., R.U.I., Medical Superinten¬
dent, District Asylum, Ballinasloe, Ireland.

1911. Moll, Jan. Marius, Doc. in Arts and Med, Utrecht Univ., L.M.S.S.A.

Lond., M.P.C., Box 2587, Johannesburg, South Africa.

1918. Molyneux, Benjamin Arthur, B.A., M.D., B.Ch.Dubl., St. Helens

House, St. Helens, Hastings.

1910. Monnington, Richard Caldicott, M.D., Ch.B., D.P.H.Edin. (Darenth

Industrial Colony, Dartford, Kent) ; c/o Rev. T. P. Monnington,
Lowick Green, Ulverston, Lancs.

1915. Monrad-Krohn, G. H., M.D., B.S., B,A.Christiania, M.R.C.S.Eng.,

M.R.C.P.Lond., M.P.C., Lecturer in Neurology at the University
and Physicifiu to the Neurological Section of Rikshospitalet,
Christiania.

1914. Montgomery, Edwin, F.R.C.S.I., L.R.C.P.I. Dipl. Psych, Manch., 1,
Tewkesbury Drive, Sedgeley Park, Manchester.

1899. Moore, Win. D., M.D., M.Ch.R.U.I., Medical Superintendent, Holloway
Sanatorium, Virgiuia Water, Surrey.

1914. Morres, Frederick, M.R.C.S.Eng., L.R.C.P.Lond. (Assistant Medical
Officer, Cane Hill Mental Hospital, Coulsdon, Surrey.

1917. Morris, Bedlington Howel, M.B., B.S.Durh., Inspector-General of
Hospitals, South Australia; Pembroke Street, College Park,
St. Peter's, S. Australia.

1896. Morton, W. B., M.D.Lond., M.R.C.S., L.R.C.P.Lond., Medical Super¬
intendent, Wonford House, Exeter.

1896. Mott, Sir Frederick W., K.B.E ., M.D., B.S., F.R.C.P.Lond., LL.D.Edin.,
F.R.S., 25, Nottingham Place, Marylebone, London, W. 1.

1896. Mould, Gilbert E., M.R.C.S., L.R.C.P.Lond., The Grange, Rotherham,

Yorks.

1897. Mould, Philip G., M.R.C.S.Eng., L.R.C.P.Lond., Overdale, Whitefield,

Manchester.

1914. Moyes, John Murray, M.B., Ch.B.Edin., D.P.M.Leeds, Tue Brook Villa,
Liverpool, E.

1919. Mules, Annie Sbortridge, M.R.C.S., L.R.C.P., Assistant House-Surgeon,

Devon and Exeter Hospital; Court Hall, Kenton, near Exeter.

1907. Mules, Bertha Mary, M.D., B.S.Durh., Court Hall, Kenton, S. Devon.

1911. Muncaster, Anna Lilian, M.B., B.Ch.Edin. (County Asylum, Chester);

home address, 8, Craylockhail Terrace, Edinburgh.

1917. Munro, Robert, M.B., Ch.B.Aberd., Assistant Medical Officer, Dorset
County Asylum, Dorchester.

1919. Murnane, John, L.R.C.P.I. & S.I. A L.M., Assistant Medical Officer,
Ballinsloe Asylum, Ireland.

1916. Murray, Jessie M., M.B., B.S.Durham, 14, Endsleigh Street, Tavistock

Square, London, W.C. 1.

1909. Myers, Charles Samuel, M.A., D.Sc., M.D., B.C.Cantab., M.R.C.S.,
L.R.C.P.Lond., 30, Montague Square, W. 1.

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1908. Navarra, Norman, M.R.C.S., L.R.C.P.Lond., City o London Mental

Hospital, near Dnrtford, Kent.

1910. Neill, Alexander YV., M.D., Ch.B.Edin., Warneford Mental Hospital,

Oxford.

1903. Nelis, William F.,M.D.Durh.,L.R.C.P.Edin.,L.R.F.P.AS.Glasg., Medical
Superintendent, Newport Borough Asylum, Caerleon, Mon.

1869. Nicolson, David, C.B., M.D., C.M.Aber., M.R.C.P.Edin., P.S.A.Scot.,
201, Royal Courts of Justice, Strand, London, W.C. 2. (Pbesidbnt,
1896-6.)

1888. Nolan, Michael J., L.R.C.P.&S.I., M.P.C., Medical Superintendent,
District Asylum, Downpatrick.

1918. Nolan, James No$l Green, M.B., B.Ch., A.B.Dub., The Hospital, Hel-
lingly Asylum, Sussex.

1909. Norman, Hubert James, M.B., Ch.B., D.P.H.Edin., Assistant Medical

Officer, Camberwell House Asylum, Peckham Road, London, S.E. 5.
(Home address: 61, Crystal Palace Park Road, Sydenham, London,
S.E. 26.)

1916. O’Carroll, Joseph, M.D., F.R.C.P., Physician Richmond and Whitworth
Hospitals; Lord Chancellor’s Medical Visitor in Lunacy; 43,
Merrion Square, Dublin.

1903. O’Doherty, Patrick, B.A., M.B., B.Ch.R.U.I., District Asylum,
Omagh.

1918. Ogilvie, William Mitchell, M.B., C.M.Aberd., Medical Superintendent,
Ipswich Mental Hospital, Ipswich.

1901. Ogilvy, David, B.A., M.D., B.Ch.Dub., Medical Superintendent, London

County Mental Hospital, Long Grove, Epsom, Surrey.

1911. Oliver, Norman H., M.R.C.S., L.R.C.P.Lond., Barrister-at-Law, Officer

in Charge, No. 4 Special Hospital for Officers, Latchmere, Ham
Common, Surrey.

1892. O’Mara, Francis, L.R.C.P.&S.I., District Asylum, Ennis, Ireland.

1902. Orr, David, M.D., C.M.Edin., M.P.C., Pathologist, County Asylum,

« Prestwich, Lancs.

1910. Orr, James H. C., M.D., Ch.B.Edin., Rosslynlee Asylum, Midlothian.
1899. Oaburne, Cecil A. P., F.R.C.S., L.R.C.P.Edin., The Grove, Old Catton,

Norwich.

1914. Oaburne, John C., M.B., B.Ch.Dubl., Assistant Medical Officer, Lindville,
Cork.

1890. Oswald, Landel R., M.B., C.M.Glasg., M.P.C., Physician Superin¬
tendent, Royal Asylum, Gartnavel, Glasgow.

1916. Overbeck-Wright, Alexander William, M.D., Ch.B., M.P.C., D.P.H.,
Superintendent, Lunatic Asylum, Agra, TJ. P., India (at present on
military duty); Lecturer on Mental Diseases, King George’s Hos¬
pital, Lucknow, and Agra Medical School, Agra. Address 12,
Rubislaw Terrace, Aberdeen.

1906. Paine, Frederick, M.D.Brux., M.R.C.S.Eng., M.R.C.P.Lond., Claybury

Mental Hospital, Woodford Bridge, Essex.

1898. Parker, William Arnot, M.B., C.M.Glasg., M.P.C., Medical Super¬
intendent, Gartloch Asylum, Gartcosh, N.B.

1898. Pasmore, Edwin Stephen, M.D., M.R.C.P.Lond., Chelsham House,

Chelsham, Surrey.

1916. Patch, Charles James Lodge, L.R.C.P.&S.Edin., Assistant Medical
Officer, Renfrew District Asylum, Dykebar, Paisley.

1899. Patrick, John, M.B., Ch.B., R.U.I., Medical Superintendent, Tyrone

Asylum, Omagh, Ireland.

1907. Peachell, George Ernest, M.D., B.S.Lond., M.R.C.S., L.R.C.P.Lond.,

M.P.C., Medical Superintendent, Dorset County Asylum, Herrison,
Dorchester.

1910. Pearn, Oscar Phillips Napier, M.R.C.S., L.R.C.P., L.S.A.Lond., Mental
Hospital, Banstead, Surrey.

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xxii Members of the Association .

1915. Pennant, Dyfrig Huws, D.S.O., M.R.C.S., L.R.C.P.Lond., Barnwood

House, Gloucester.

1913. Penny, Robert Augustus Greenwood, M.R.C.S., L.R.C.P.Lond., Devon
County Asylum, Exminster.

1893. Perceval, Frank, M.R.C.S., L.R.C.P.Lond., Medical Superintendent,
County Asylum, Prestwich, Manchester, Lancashire.

1911. Petrie, Alfred Alexander Webster, M.I)., B.S.Lond., Ch.B., F.R.C.S.

Edin., Assistant Medical Officer, Epileptic Colony, Epsom.

1878. Philipps, Sutherland Rees, M.D., C.M.Q.U.I., F.R.G.S., Bredon, Fisher
Street, Paignton.

1908. Phillips, John George Porter, M.D., B.S.Lond., M.R.C.S., M.R.C.P.Lond.,
M.P.C., Resident Physician and Superintendent, Bethlem Royal
Hospital, Lambeth, London, S.E. 1.

1910. Phillips, John Robert Parry, M.R.C.S., L.R.C.P.Lond., Assistant Medical
Officer, City Asylum, Bristol.

1906. Phillips, Nathaniel Richard, M.D.Brux., M.R.C.S., L.R.C.P.Lond., Assis¬
tant Medical Officer, County Asylum, Abergavenny, Monmouth¬
shire.

1905. Phillips, Norman Routh, M.D.Brux., M.K.C.S., L.R.C.P.Lond., 67,
Billing Road, Northampton.

1891. Pierce, Bedford, M.D., F.R.C.P.Lond., Medical Superintendent, The
Retreat, York. (Eon. Secretary N. and M. Division 1900-8.)
(President.)

1888. Pietersen, J. F. G., M.R.C.S., L.R.C.P.Lond., Ashwood House, Kingswin-

ford, near Dudley, Stafford.

1896. Planck, Charles, M.A.Camb., M.R.C.S., L.R.C.P.Lond., Medical Super¬
intendent, Brighton County and Borough Asylum, Haywards Heath.

1912. Plummer, Edgar Curnow, M.R.C.S., L.R.C.P.Lond. (Medical Superin¬

tendent, Laverstock House, Salisbury); British Expeditionary Force.

1889. Pope, George Stevens, L.R.C.P.&S.Edin., L.R.F.P.&S.Glasg., Heigham

Hall, Norwich.

1918. Potts, William A., M.A.Camb., M.D.Edin.&Birm., M.R.C.S., L.R.C.P,
Lond., Medical Officer to the Birmingham Committee for the Care
of the Feeble-minded , 118, Hagley Road, Birmingham.

1876. Powell, Evan, M.R.C.S.Eug., L.S.A., Medical Superintendent, City
Lunatic Asylum, Nottingham.

1910. Powell, James Farquharson, M.R.C.S., L.R.C.P., D.P.H.Lond., M.P.C.,
Assistant Medical Officer, The Asylum, Caterham, Surrey.

1916. Power, Patrick William, L.R.C.P., L.R.C.S., Senior Assistant Medical

Officer, County Asylum, Chester.

1908. Prentice, Reginald Wickham, L.M.S.S.A.Lond., Beanworth Manor,
Alresford, Hants.

1918. Prideaux, John Joseph Francis Engledue, M.R.C.S., L.R.C.P.Lond.,
Resident Medical Officer, Graylingwell War Hospital, Chichester.
1901. Pngh, Robert, M.D., Ch.B.Edin., Medical Superintendent, Brecon and
Radnor Asylum, Talgarth, S. Wales.

1904. Race, John Percy, M.R.C.S., L.R.C.P., L.S.A.Lond., Journals and
notices to Winterton Asylum, Ferryhill, Durham (Wheatley Hill,
Doncaster).

1899. Rainsford, F. E., M.D., B.A.Dubl., L.R.C.P.I., L.R.C.P.&S.E., Resident
Physician, Stewart Institute, Palmerston, co. Dublin.

1894. Rambaut, Daniel F., M.A., M.D., B.Ch.Dub., Medical Superintendent,
St. Andrew’s Hospital, Northampton.

1910. Rankine, Surg. Roger Aiken, R.E., M.B., B.S., M.R.C.S.,L.R.C.P.Lond.,
M.P.C.

1889. Raw, Nathan, C.M.G., M.P., M.D., B.S.Durh., L.S.Sc., F.R.C.S.Edin.,
M.R.C.P.Lond., M.P.C., 58, Harley Street, W. 1.

1870. Rayner, Henry, M.D.Aberd., M.R.C.P.Edin., Upper Terrace House,
Hampstead, London, N.W. 3. (President, 1884.) (General
Secretary , 1877-89.) (Co-Editor of Journal 1895-1911.)

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1913. Read, Charles Stanford, M.D.Lond., M.R.C.S., L.R.C.P.Lond., Assistant

Medical Officer, Fisher ton House, Salisbury.

1903. Read, George F., L.R.C.S.&P.Edin., Hospital for the Insane, New
Norfolk, Tasmania.

1899. Rediugton, John, F.R.C.S.&L.R.C.P.I., Portrane Asylum, Don abate,
Co. Dublin.

1911. Reeve, Ernest Frederick, M.6., B.S.Lond., M.R.C.S., L.R.C.P.Lond.,
Senior Assistant Medical Officer, County Asylum, Rainhill, Lancs.
1911. Reid, Dquiel McKinley, M.D., Ch.B.Glasg., Hawkhead Mental Hospital,
Cnrdonald, Glasgow.

1910. Reid, William, M.A.Sc. And., M.B., Ch.B.Edin., Senior Assistant Medical

Officer. Burntwood Asylum, Lichfield.

1886. Revington, George T., M.A., M.D., B.Ch.Dubl., M.P.C., Medical Superin¬

tendent, Central Criminal Asylum, Dundrum, Ireland.

1899. Rice, David, M.D.Brux., M.R.C.S., L.R.C.P.Lond., D.P.H., Medical
Superintendent, City Aisylura, Hillesdon, Norwich.

1897. Richard, William J., M.A., M.B., Ch.M.Glasg., Merryflats, Govan,
Glasgow.

1899. Richards, John, M.B., C.M.Edin., F.R.C.S.E., Medical Superintendent,

Joint Counties Asylum, Carmarthen.

1911. Roberts, Henry Howard, M.D., Ch.B.Edin., D.P.H.Glasg., Ennerdale,

Haddington, Scotland.

1914. Roberts, Ernest Theophilus, M.D., C.M.Edin., D.P.H.Camb., M.P.C.,

Hawkstonc, 58, South Brae Drive, Jordanhill, Glasgow.

1903. Roberts, Norcliffe, O.B.JE., M.D., B.S.Durh., Senior Assistant Medical
Officer, Horton Mental Hospital, Epsom, Surrey.

1887. Robertson, Geo. M., M.D., C.M., F. R.C.P.Edin., M.P.C., Physician-Super¬

intendent, Royal Asylum, Morningside, Edinburgh.

1908. Robertson, George Dunlop, L.R.C.S.&P.Edin., Dipl. Psycb., Assistant
Medical Officer, District Asylum, Hart wood, Lanark.

1916. Robertson, Jane I., M.B., Ch.B.Glasg., Dogleap, Limavady, Co.
Derry.

1895. Robertson, William Ford, M.D., C.M.Edin., 60, Northumberland Street,

Edinburgh.

1900. Robinson, Harry A., M.D., Ch.B.Vict., 140, Edge Lane, Liverpool.

1911. Robson, Capt. Hubert Alan Hirst, M.R.C.S., L.R.C.P.Lond., Punjaub

Asylum, India.

1914. Rodger, Murdoch Mann, M.D., Ch.B.Glas., The Rowans, Bothwell,
Scotland.

1908. Rodgers, Frederick Millar, M.D., Ch.B.Vict., D.P.H., Senior Medical
Officer, County Asylum, Winwick, Lancs.

1906. Rolleston, Charles Frank, B.A., M.B., Ch.B.Dub., Assistant Medical
Officer, County of Loudon Manor Mental Hospital, Epsom.

1896. Rolleston, Lancelot W., C.B.E. , M.B., B.S.Durh. (Medical Super¬

intendent, Middlesex County Asylum) ; Napsbury Mental Hospital,
Napsbury, near St. Albans.

1688. Ross, Chisholm, M.D.Syd., M.B., C.M.Edin., 151, Macquarie Street,
Sydney, New South Wales.

1918. Ross, Dermid Maxwell, M.B., Ch.B.Edin., Physician-Superintendent,
Janies Murray’s Royal Asylum, Perth.

1910. Ross, Donald, M.B., Ch.B.Edin., Argyll and Bute Asylum, Loch¬
gilphead.

1899. Rotherham, Arthur, M.A., M.B., B.C.Cantab., Commissioner under
Ment. Defec. Act, Board of Control, 66, Victoria Street, West¬
minster, London, S.W. 1.

1906. Rowan, Marriott Logan, B.A., M.D.R.U.I., Medical Superintendent,
Derby County Asylum, Mickleover.

1883. Rowland, E. D., M.B., C.M.Edin., 71, Main Street, George Town,
Demerara, British Guiana.

1902. Rows, Richard Gundry, C.R.E., M.D.Lond., M.R.C.S., L.R.C.P.Lond.

(Pathologist, County Asylum, Lancaster), Tooting Neurological
Hospital, Church Lane, Tooting, S.W.

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1877. Russell, Arthur P., M.B., C.M., M.R.C.P.Edin., The Lawn, Lincoln.
1912. Russell, John Ivison, M.B., Ch.B.Glasg., Jean field, 18, Woodend Drive,
Jordan Hill, Glasgow.

1915. Russell, William, M.B., Ch.B.Edin., Dip.Psych.Bdin., D.T.M.Edin.,
Assistant Physician, Pretoria Mental Hospital, S. Africa.

1912. Rutherford, Cecil, M.B., B.Ch.Dubl.,'Assistant Medical Officer, Holloway

Sanatorium, Virginia Water, Surrey.

1907. Rutherford, Henry Richard Charles, F.R.C.S.I., L.R.C.P.I., D.P.H., St.
Patrick’s Hospital, James’s St., Dublin.

1896. Rutherford, James Mair, M.B., C.M.,F.R.C.P.Edin., M.P.C., Brislington
House, Bristol.

1913. Ryan, Ernest Noel, B.A., M.D., B.Ch.Duh., 6th London Field

Ambulance (T.).

1902. Sail, Ernest Frederick, M.R.C.S., L.U.C.P.Lond., Medical Superinten¬
dent, Borough Asylum, Canterbury.

1908. Samuels, William Frederick, L.M.&L.S.Dubl., Medical Superintendent,

Central Asylum,Tangong, Rambutan,Perak,Federated Malay States.
1894. Sankey, Edward H. O., M.A., M.B., B.C.Cantab., Resident Medical
Licensee, Boreatton Park Licensed House, Baschurch, Salop.
Sankey, R. H. Heurtley, M.R.C.S.Eng., 3, Marston Ferry Road,
Oxford.

1873. Savage, Sir Geo. H., M.D., F.R.C.P.Lond., 26, Devonshire Place,
London, W. 1 . ( Late Editor of Journal .) (President, 1886.)

1906. Scanlan, John J., L.R.C.P.&S.Edin., L.R.F.P.&S.Glasg.,D.P.H., 1, Castle
Court, Cornhill, Loudon, E.C. 3.

1896. Scott, James, M.B., C.M.Edin.. 98, Baron’s Court Road, West Kensing¬
ton, London, W. 14.

1915. Scott, James McAlpine, M.D., Ch.B.Glasg., Junior Assistant Medical
Officer, Stirling District Asylum, Larbert.

1889. Scowcroft, Walter, M.R.C.S., L.R.C.P.I., Medical Superintendent, Royal
Lunatic Hospital, Cheadle, near Manchester.

1911. Scroope, Geoffrey, M.B., B.Ch.Dub., Assistant Medical Officer, Central

Asylum, Dun drum.

1880. Seccombe, George 8., M.R.C.S., L.R.C.P.Lond., c/o Messrs. H. S. King
and Co., 65, Cornhill, London, E.C. 3.

1912. Sergeant, John Noel, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond., Medical

Superintendent, Newlands House, Tooting Bee Common, London,
S.W. 17. ( Secretary South-Eastern Division since 1913.)

1913. Shand, George Ernest, M.D., Ch.B.Aber.; (Senior Assistant Medical

Officer, City Mental Hospital, Wiuson Green, Birmingham). Tern*
porary address: 4, Odessa Road, Harlesdcu, London, N.W. 10.
Permanent address: 307, Gilottt Road, Edgbaston, Birmingham.
1901. Shaw, B. Henry, M.B., B.Ch.R.U.I., Assistant Medical Officer, County
Asylum, Stafford.

1905. Shaw, Charles John, M.D., Ch.B., F.R.C.P.E., Medical Superintendent,
Royal Asylum, Montrose.

1915. Shaw, Hugh Kirkland, M.B., Ch.B.Edin., Assistant Medical Officer,
Stirling District Asylum, Larbert.

1917. Shaw, John Custance, M.R.C.S.Eng., L.R.C.P.Lond., Medical Superin¬
tendent, West Ham Borough Asylum, Goodmayes, Essex.

1904. Shaw, Patrick, L.R.C.P.&S.Edin., Medical Superintendent, Hospital for
Insane, Ararat, Victoria, Australia.

1909. 8haw, William Samuel J., M.B., B.Ch.R.U.I., Superintendent, North

Veravola, Poona, India.

1909. Shepherd, George Ferguson, F.R.C.S., L.R.C.P.Irel., D.P.H., 9, Ogle
Terrace, South Shields.

1900. Shera, John E. P., M.D.Brux., L.R.C.P.&S.Irel., Somerset County Asylum,
Wells, Somerset.

1912. Sheridan, Gerald Brinsley, M.B., B.Ch.R.U.I., Valkenberg Mental
Hospital, Cape Town, S. Africa.

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Members of the Association .

1914. Sherlock, Edward Barbell, M.D., B.Sc., D.P.H.Lond., Medical Superin¬
tendent, Darenth Industrial Colony, Dartford.

1914. Shield, Hubert, M.C. , M.B., B.S.Durh., Assistant Medical Officer
Gateshead Borough Asylum, Stannington, Newcastle-on-Tyne.

1877. Shnttleworth, George E., B.A.Lond., M.D.Heidelb., M.R.C.S. and L.S.A.

Lond., 86, Lambolle Road, Hampstead, London, N.W. 3.

1901. Simpson^ Alexander, C.B.E., M.A., M.D., C.M.Aber., Medical Superin¬
tendent, County Asylnm, Winwick, Newton-le-Willows, Lancashire.

1905. Simpson, Edward Swan, M.D., Ch.B.Edin., East Riding Asylum,
Beverley, Yorks.

1888. Sinclair, Eric, M.D., C.M.Glasg., Inspector-General of Insane, Richmond
Terrace, Demain, Sydney, N.S.W.

1891. Skeen, James Humphry, M.B., Ch.M.Aber., M.P.C., Medical Super¬
intendent, Fife and Kinross District Asylum, Cupar, N.B.

1914. Slaney, Chas. Newnham, M.R.C.S., L.R.C.P.Lond., The Elms, Parkhurst,
I.W.

1901. Slater, George N. O., M.D.Lond., M.R.C.S., L.R.C.P.Lond., Assistant
Medical Officer, Essex County Asylum, Brentwood.

1914. Smith, Charles Kelman, M.B., Ch.B.Aberd., Assistant Medical Officer,
Parkside Asylum, Macclesfield.

1910. Smith, Gayton Warwick, M.D.Lond., B.S.Durh., D.P.H.Cantab.,

M.R.C.S., L.R.C.P.Lond., Assistant Medical Officer, Springfield
Mental Hospital, Tooting, London, S.W. 17.

1905. Smith, George William, M.B., Ch.B.Edin., Chiswick House, Chiswick.
1907. Smith, Henry Watson, M.D., Ch.B.Aberd., Medical Superintendent,

Lebanon Hospital for the Insane, Asfurujeh, near Beyrout,
Syria.

1899. Smith, John G., M.D., C.M.Edin., Firbank, Burghill, Hereford.

1885. Smith, R. Percy, M.D., B.S., F.R.C.P.Lond., M.P.C., 86, Queen
Anne Street, Cavendish Square, London, W. 1. ( General Secretary,
1896-7. Chairman Educational Committee, 1899-1903.) (Pbesi-
DBlfT, 1904-5.)

1918. Smith, Thomas Cyril, M.B., B.Ch.Edin., County Asylum, Gloucester.

1911. Smith, Thomas Waddelow, F.R.C.S.Eng., L.R.C.P.Lond., M.P.C., Assis¬

tant Medical Officer, City Asylum, Mapperley Hill, Nottingham.

1884. Smith, W. Beattie, F.R.C.S.Edin., L.R.C.P.Edin., 4, Collins Street,

Melbourne, Victoria.

1914. 8mith, Walter H., B.A., M.D., B.Ch.Dub., Senior Assistant Medical
Officer, County Asylum, Shrewsbury.

1899. Smyth, Walter S., M.B., B.Ch.R.U.I., Assistant Medical Officer, County
Asylum, Antrim.*

1918. Somerville, Henry, B.Sc., M.R.C.S.Eng., L.R.C.P.Lond., F.C.S., Harrold,
Sbarnbrook, Bedfordshire.

1885. Soutar, James Greig, M.B., C.M.Edin., M.P.C., 20, Royal Parade,

Cheltenham. (President, 1912-13.)

1906. Spark, Percy Charles, M.R.C.S., L.R.C.P.Lond., Medical Superintendent,

London County Asylum, Banstead, Surrey.

1875. Spence, J. Beveridge, M.D., M.C.Q.U.I., Medical Superintendent, Burnt-
wood Asylum, near Lichfield. (First Registrar, 1892-1899; Chair -
man Parliamentary Committee, 1910-12.) (President, 1899-

1900.)

1891. Stansfield, T. E. K., C.B.E., M.B., C.M.Edin., Medical Superintendent,
* London County Mental Hospital, Bexley, Kent.

1901. Starkey, William, M.B., B.Ch.R.U.I,, Medical Superintendent, Borough
Asylum, Blackadon, Ivybridge, S. Devon.

1907. Steele, Patrick, M.D., Ch.B., M.R.C.P.Edin., Assistant Medical Officer,

District Asylum, Melrose.

1898. Steen, Robert H., M.D.Lond., M.R.C.P.Lond., Medical Superintendent,
City of London Mental Hospital, Stone, Dartford; Professor of
Psychological Medicine and Out-patient Physician, King's College
Hospital. (Hon. Sec. 8.E. Division, 1905-10; Acting Gen. Sec.
and Gen. Sec. 1915-19.)

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xxvi Members of the Association.

1914. Stephens, Harold Freize, M.R.C.S.Lond., L.R.C.P.Eng., 9, Belmont
Avenue, Palmer's Green, Middlesex.

1914. Stevenson, George Henderson, M.B., Ch.B.Edin., D.P.H.Lond., Joyce

Green Hospital, Hartford, Kent.

1912. Stevenson. William Edward, M.B., B.S.Durh., Winncoll Down Camp,

Winchester.

1909. Steward, Sidney John, M.D., D.S.O., B.C.Cantab., M.R.C.S., L.R.C.P.

Loud., Assistant Medical Officer, Langton Lodge, Farncombe,
Surrey.

1915. Stewart, A. H. L., M.R.C.S., 72, Wimpole Street, London, W. 1.

1868. Stewart, James, B.A.Beif., F.R.C.P.Ed., L.R.C.S.I., “ Donegal," 82,
Kingsmcad Road, Tulse Hill, London, S.W. 2.

1913. Stewart, Ronald, M.B., Ch.B.Glasg., Gartloch Asylum, Gsrtcosh,

Glasgow.

1887. Stewart, Rothsay C., M.R.C.S.Eug., L.S.A.Lond., Medical Superinten¬
dent, County Asylum, Narborough, near Leicester.

1914. Stewart, Roy M., M.B., Ch.B.Ediu. (Assistant Medical Officer, County

Asylum,Prestwich); Mediterranean Expeditionary Force c/o G.P.O.,
E.C. 1.

1905. Stilwell, Henry Francis, L.R.C.P.&S.E., Hayes Park, Hayes, Middle*
sex.

1899. Stilwell, Reginald J., M.R.C.S., L.R.C.P.Lond., Moorcroft House, Hil¬

lingdon, Middlesex.

1897. Stoddart, William Henry Butter, M.D., B.S., F.R.C.P.Lond., M.R.C.S.

Eng., M.P.C., Harcourt House, Cavendish Square, London, W. 1.
(Hon. Sec. Educational Committee , 1908-1912.)

1909. Stokes, Frederick Ernest, M.D., Ch.B.Glasg., D.P.H.Cautab., Assistant
Medical Officer, Borough Asylum, Portsmouth.

1905. Strathearn, John, M.D., Ch.B.Glasg., F.R.C.S.E., 23, Magdalen Yard
Road, Dundee.

1903. Stratton, Percy Haughton, M.R.C.S., L.R.C.P.Lond., 10, Hanover
Square, Loudon, W. 1.

1885. Street, C. T., M.R.C.S., L.R.C.P.Lond., Haydock Lodge, Ashton,

Newton-le-Willows, Lancashire.

1909. Stuart, Frederick J., M.R.C.S., L.R.C.P.Lond., Senior Assistant Medical

Officer, Northampton County Asylum, Bcrrywood.

1900. Sturrock, James Prain, M. A St. And., M.D., C.M.Edin., 25, Palmerston

Place, Edinburgh.

1886. Suffern, Alex. C., M.D., M.Ch.R.U.I., Medical Superintendent, Rubery

Hill Asylum, near Brorasgrove, Worcestershire.

1894. Sullivan, William C., M.D., B.Ch.R.U.L, Hampton Criminal Lunatio
Asylum, Retford, Notts.

1918. Sutherland, Francis, M.B., Ch.B.Edin., Senior Assistant Physician, Royal

Asylum, Aberdeen.

1910. Sutherland, Joseph Roderick, M.B., Ch.B.Glasg., M.R.C.S., L.R.C.P.

Lond., D.P.H., County Sanatorium, Stonehouse, Lanarkshire.

1919. Suttie, Ian D.JM.B., Ch.B.Glas. (Assistant Medical Officer, Royal Asylum,

Glasgo\^71055, Great Western Road, Glasgow.

1908. Swift, Eric W. D., M.B.Lond., Medical Superintendent, Government
Asylum, Bloemfontein.

1908. Tattersall, John, M.D.Lond., M.R.C.S., M.R.C.P.Lond., Assistant
Medical Officer, Loudon County Asylum, Hanwell, London, W. 7.
1910. Taylor, Arthur Loudoun, M.B., Ch.B., B.Sc., M.R.C.P.Edin., Craigend
Neurasthenic Hospital, Craigend Park, Liberton, Midlothian.

1897. Taylor, Frederic Ryott Percival, M.D., B.S.Lond.,M.R.C.S.Eug.,L.R.C.P.

Lond., Medical Superintendent, East Sussex Asylum, Hellingly.
1918. Thienpont, Rudolph, M.D., Temporary Assistant Medical Officer, Cana
Hill Mental Hospital, Coulsdon, Surrey.

1908. Thomas, Joseph D., B.A., M.B., B.C.Cantab., Northwoods House, Winter^
bourne, Bristol.

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Members of the Association . xxvii

1911. Thomas, William Rees, M.D., B.S.Lond., M.R.C.S., M.R.C.P.Lond.,
M.P.C., Mosside, Maghull, near Liverpool.

1880. Thomson, David G., C.3. 2?., M.D., C.M.Edin., Medical Superintendent,

County Asylum, Thorpe, Norfolk. (Pbbsidsht, 1914-18.)

1908. Thomson, Herbert Campbell, M.D., F.R.C.P.Lond., Assist. Physioian
Middlesex Hospital, 84, Queen Anne Street, London, W. 1.

1905. Tidbury, Robert, M.D., M.Ch. R.U.I., Heathlands, Foxhall Road,

Ipswich.

1901. Tighe, John V. G. B., M.B., B.Ch.R.U.I., Medical Superintendent,
Gateshead Mental Hospital, Stannington, Northumberland.

1914. Tisdall, C. J., M.B., Ch.B., Tue Brook Villa, Liverpool.

1908. Topham, J. Arthur, B.A.Cantab., M.R.C.S., L.R.C.P.Lond., Coqpty
Asylum, Chartham, Kent.

1896. Townsend, Arthur A. D., M.D., B.Ch.Birm., M.R.C.S., L.R.C.P.Lond.,
Medical Superintendent, Hospital for Insane, Barnwood House,
Gloucester.

1904. Treadwell, Oliver Fereira Naylor, M.R.C.S.Eng., L.S.A.Lond., 90, St.
George’s Square, London, S.W. 1.

1908. Tredgold, Alfred F., M.D., F.R.S.Edin., L.R.C.P.Lond. M.R.C.S.Eng.,
6, Dapdune Crescent, Guildford, Surrey.

1908. Tuach-MacKenzie, William, M.D., Ch.B.Aberd., Medical Superintendent,

Royal and District Asylums, Dundee.

1881. Tuke, Charles Moleswortb, M.R.C.S.Eng., Chiswick House, Chiswick,

W. 4.

1888. Tuke, John Batty, M.D., C.M., F.R.C.P.Edin., Resident Physician,

New Saughton Hall, Polton, Midlothian.

1915. Tnllocb, William John, M.D.St. Andrews, Director Western Asylums

Research Institute, 10, Claython Road, Glasgow.

1906. Turnbull, Peter Mortimer, Af.C., M.B., B.Ch.Aberd., Tooting Bee

Asylum, Tooting, London, S.W. 17.

1909. Turnbull, Robert Cyril, M.D.Lond., M.R.C.S., L.R.C.P.Lond., Medical

Superintendent, Essex County Asylum, Colchester.

1889. Turner, Alfred, M.D., C.M.Edin., Plympton House, Plympton,

S. Devon.

1906. Turner, Frank Douglas, M.B.Lond., M.R.C.S., L.R.C.P.Lond., Medical
Officer, Royal Eastern Counties Institution, Colchester.

1890. Turner, John, M.B., C.M.Aberd., Medical Superintendent, Essex County

Asylum, Brentwood.

1917. Vevers, Oswald Henry, M.R.C.S., L.R.C.P.Lond., Norton Vicarage*
Evesham.

1904. Vincent, George A., M.B., B.Ch.Edin.,Assistant Medical Superintendent,
St. Ann’s Asylum, Port of Spain, Trinidad, B.W.I.

1894. Vincent, William James N., C.B.JS ., M.B., B.S.Durh., M.R.C.S.,
L.R.C.P.Lond., Medical Superintendent, Wadsley Asylum, near
Sheffield.

1914. Vining, Charles Wilfred, M.D., B.S., M.R.C.P.Lond., D.P.H., M.P.C.,
Assistant Physician, Leeds General Infirmary, 40, Park Square,
Leeds.

1919. Waddell, Arthur Robert, M.D., C.M.Glasg., Deputy Commissioner,
Medical Services, Exeter Area; Roseland, Baldock, Herts.

1918. Walford, Harold R. 8., M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical
Officer, Kent County Asylum, Banning Heath, Maidstone.

1914. Walker, Robert Clive, M.B., Ch.B.Edin., West Riding Asylum, Menston*
near Leeds.

1908. Wallace, John Andrew Leslie, M.D., Ch.B.Edin., M.P.C., Mental
Hospital, Callan Park, Sydney, N.S.W.

1918. Wallace, Vivian, L.R.C.P. A S.I., Assistant Medical Officer, Mullingar
District Asylum, Mullingar.

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1880. Warnock, John, C.M.G.,hlL.D., C.M., B.Sc.Edin., Medical Superintendent,
Abbasiyeh Asylum, nr. Cairo, Egypt.

1895. Waterston, Jane Elizabeth, M.D.Bruz., L.R.C.P.I.,L.R.C.S.Edin.,M.P a C.,
85, Parliament Street, Box 78, Cape Town, South Africa.

1801 Watson, George A., M.B., C.M.Edin., M.P.C., Lyons House, Rainhill,
Liverpool.

1008. Watson,H. Ferguson,M.D.,Ch.B.Glas.,L.R.C.P.&S.E.,L.R.F a P.&S.Glas.,
D.P.H., 25, Palmerston Place, Edinburgh.

1010. Webb-Johnson, Cecil, M.B., Ch.B.Vict., 150, Harley Street, W. 1.

1911. Webber, Leonard Mortis, M.R.C.S., L.R.C.P.Lond., Assistant Medical
Officer, Netberue, Merstliam, Surrey.^

l^JO. Westrup, Joseph Perceval, M.R.C.S.Eng., L.R.C.P.Lond., Medical
Officer, Fisherton House Mental Hospital, Salisbury.

1910. Wheeler, Frederic Francis, M.R.C.S.Eng., L.R.C.P.Lond., Assistant

Medical Officer, Long Grove Mental Hospital, Epsom, Surrey.

1911. White, Edward Barton C., M.R.C.S., L.R.C.P.Lond., Senior Assistant

Medical Officer, Cardiff City Mental Hospital, Whitchurch, S. Wales.

1884. White, Ernest William, O.B.E. , M.B.Lond., M.R.C.P.Lond., Betley

House, nr. Shrewsbury. (Hon. Sec. South-Eastern Division,
1897-1000.) (Chairman Parliamentary Committee, 1904-7.)
(President 1903-4.)

1905. Whittington, Richard, M.A., M.D.Oxon., M.R.C.S., L.R.C.P.Lond.,
1, Eaton Gardens, Hove, Sussex.

1889. Whitwell, James Richard, M.B., C.M.Edin., Medical Superintendent,
Suffolk County Asylum (St. Audry’s Hospital), Melton, Suffolk.
1018. Wilkins, William Dougins, M.B., Ch.B.Vict., M.R.C.S., L.R.C.P.

Lond., County Mental Hospital, Cheddleton, Leek, Staffs.

1900. Wilkinson, H. B., M.R.C.S., L.R.C.P.Lond., Assistant Medical Officer,
Plymouth Borough Asylum, Blackadon, Ivybridge, South Devon.
1887. Will, John Kennedy, M.A., M.D., C.M.Aberd., M.P.C., Bethnal House,
Cambridge Road, London, N.E.l.

1014. Williams, Charles, L.R.C.P. A S.Edin., L.S.A.Lond., Assistant Medical
Officer, The Warneford, Oxford.

1007. Williams, Charles E. C., M.A., M.D., B.Ch.Dubl.; Branksome Chine
House, B rank so me Park, Bournemouth.

1005. Williams, David John, M.R.C.S., L.R.C.P.Lond., Medical Superintendent,
The Asylum, Kingston, Jamaica.

1915. Williams, Gwilym Ambrose, M.R.C.S.Eng., L.R.C.P.Lond., Pathologist
and Assistant Medical Officer, East Sussex County Asylum,
Hellingly.

1016. Wilson, Marguerite, M.B., Ch.B.Glasg., The Retreat, York.

1012. Wilson, Samuel Alexander Kinnier, M.A., M.D., B.Sc.Edin., F.R.C.P,
Lond., Registrar, National Hospital, Queen’s Square, 14, Harley
Street, London, W. 1.

1899. Wolseley-Lewis, Herbert M.D.Brux., F.R.C.S.Eng., L.R.C.P.Lond.,

Medical Superintendent, Kent County Asylum, Banning Heath,
Maidstoue. (Secretary Parliamentary Committee, 1907*12. Chair¬
man of same since 1912.)

1860. Wood, T. Outterson, M.D.Durli., M.R.C.P.Lond., F.R.C.P., F.R.C.S.

Edin., 7, Abbey Crescent, Torquay. (President, 1905-8.)

1012. Woods, James Cowan, M.D., B.S.Lund., M.R.C.S., L.R.C.P.Lond.,
10, Palace Green, Kensington, London, W. 8.

1885. Woods, J. F., M.D.Durli., M.R.C.S.Eng,, 7, Harley Street, Cavendish

Square, London, W. 1.

1012. Wootton, John Charles, M.R.C.S.Eng., L.R.C.P.Lond., Haydock Lodge,
Newton-le-Willows, Lancs.

1900. Worth, Reginald, O.B.E. , M.B., B.S.Durh., M.R.C.8., L.R.C.P.Lond.,

Medical Superintendent, Springfield Mental Hospital, nr. Tooting,
S.W. 17. ( General Secretary 1919.)

1017. Wright, Maurice Beresford, O.B.E., M.D., C.M.Edin. (118, Harley

Street, London, W. 1); 10, Palace Green, Kensington, London,
W. 8.

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Members of the Association.

1862. Yellowlees, David, LL.D.Glasg., M.D.Edin., F.R.F.P.AS.Glasg., "Grange*
neuk,” Fountainhall Road, Edinburgh. (President, 1890.)

1914. Yellowlees, Henry, O.B.E ., M.D., Ch.B.Glasg., F.R.F.P.S.Glasg., 151,
Morningside Drive, Edinburgh.

1910. Younger, Edward George, M.D.Brux., M.R.C.P., M.R.C.S., L.S.A.Lond.,
D.P.H., Physician to the Finsbury Dispensary, 2, Mecklenburgh
Square, London, W.C. 1.

Ordinary Mbmbbrs . 626

Honorary Members . 26

Corresponding Mbmbbrs . 9

Total. 661

Members are particularly requested to send changes of address, etc ., to The
General Secretary , 11, Chandos Street, Cavendish Square, London,
W. 1, and in duplicate to the Printers of the Journal, Messrs. Adlard
Son# West Newman, Ltd., 23, Bartholomew Close, London, E C. 1.

OBITUARY.

Honorary Members.

1887. Schule, Heinrich, M.D., Illenau, Baden, Germany.

1881. Tamburiui, A., M.D., Reggio-Emilia, Italy.

Members.

1869. Aldridge, Chas., M.D., C.M.Aber., L.R.C.P.Lond., Bellevue House,
Plympton, Devon.

1902. Beale-Browne, Thomas Richard, M.R.C.S.Eng., L.R.C.P.Lond., c/o
P.M.O. Lagos, Nigeria, West Africa.

1897. Dove, Emily Louisa, M.B.Lond., 11, Jenner House, Hunter Street,
Brunswick Square, London, W.C. 1.

1884. Drapes, Thomas, M.B.Dubl., L.R.C.S.I., Medical Superintendent, District
Asylum, Enniscorthy, Ireland; Milleen,” Dalkey, Co. Dublin.
(Presidbnt-blbct, 1910-11; Co* Editor of Journal since 1912.)
1917. Fearnsides, Edwin Greaves, M.D.Camb., B.C., M.A., 46, Queen Anne
Street, Cavendish Square, London, W. 1.

1891. Mercier, Charles A., M.D.Lond., F.R.C.P., F.R.C.S.Eng., late Lecturer
on Insanity, Westminster Hospital; Moorcroft, Park stone, Dorset.
(Secretary Educational Committee, 1893-1905. Chairman do. from
1905-12.) (President, 1908-9.)

1902. Watson, Frederick, M.B., C.M.Edin., Elm Lodge, Clay Hill, Enfield.

1888. Wiglesworth, Joseph, M.D., F.R.C.P.Lond., Springfield House, Wins-

combe, Somerset. (Pbbsidbnt, 1902-3.)

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JOURNAL OF MENTAL SCIENCE, JANUARY, 1920.

Charles Arthur Mekcikk, M.D.Lond., F.R.C.P.Lond., F.R.C.S.Eng.
Obiit September 2nd, 1919. President 1908-9.

A (Hard & Son & ll'cst Xcivman, Ltd.

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THE

JOURNAL OF MENTAL SCIENCE

[Published by Authority of the Medico-Psychological Association
of Great Britain and Ireland.'}

No. 272 JANUARY, 1920. VOL. LXV 1 .

CHARLES ARTHUR MERCIER.

M.D.Lond., F.R.C.P.Lond., F.R.C.S.Eng. B. 1852: D. 1919.

Only two years have passed since the death of one of the most
eminent of our scientific interpreters and teachers in'the province of
mental diseases, and now another has gone from us whose intellectual
power and rare attainments were in many respects strikingly comparable
with those of Henry Maudsley. This likeness has doubtless been
already noted by many. It struck me some thirty-five years ago, at the
outset of my acquaintance with Mercier and some of his works and
from my knowledge of Dr. Maudsley’s writings, since the first edition of
his Physiology and Pathology of Mind was published in 1867. But
as the characteristics which these memorable men had in common
have probably never been noted in print, I venture here to make brief
mention of some of them. It would perhaps be as easy to draw a con¬
trast as a comparison, especially as regards some of their philosophical
views, their individual and social qualities, and their literary styles. But
my personal knowledge of Dr. Maudsley was not intimate enough to
fit me to speak on some of these points, and the others speak for themselves
in each author’s written works.

Both Maudsley and Mercier possessed in large measure the scientific
mind, and their works were marked alike by a dominant determination
to search out as thoroughly and explain as clearly and fully as their
powers allowed the subject they had chosen for the chief labour of their
lives. The terms they used were so clearly defined that their arguments
left but few gaps for strictly logical criticism, however unacceptable by
some their conclusions may have been. Both men were trenchant and
alert in controversy, and, perhaps in part consequence, neither was always
popular among those who were but slightly acquainted with them. In
their wide and intimate knowledge of the best of English literature both
excelled, and these and other acquirements, dmpled with their excep¬
tional faculty of retentive memory, supplied them with rich stores of

LXVI.

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CHARLES ARTHUR MERCIER,

[Jan.,

illustrations and examples which contributed largely to the charm and
clarity of their writings. Both, too, had a mass of readily quotable
knowledge of the Bible, Shakespeare, and numerous other classics, to
an extent not often attained even by purely literary specialists.

In making this short comparison I am reminded of the pleasure and
profit which I owe to the works of both Maudsley and Mercier. The
former impressed me early with a strong preference for the study of
subjects based on scientific knowledge rather than on tradition, while
Mercier’s writings on insanity, some time after I had taken to medical
work and was becoming interested in psychological medicine, gave me
the kind of guidance that I had been looking for in vain. And still,
after frequent re-readings, they seem to me to have achieved more com¬
pletely than any others the immensely difficult task of making plain,
to the serious beginner needing enlightenment, the many rough places
that obstruct the approach to knowledge of this attractive but perplexing
subject. But I am not intending here to compare these books with
other and larger works which abound in detailed information, and are
expressly written for those who specialise as alienist physicians.

Mercier spent his life in strenuous effort. In some respects his boy¬
hood recalls that of Charles Dickens. After a few years at Merchant
Taylors’ School he sought his own living by reason of family circum¬
stances, and engaged in various employments where he gained some
varied knowledge and experiences which stood him in good stead later.
During this time he went to sea as a cabin-boy, and afterwards served
as a clerk in a London warehouse. Ultimately he was enabled to
commence medical-student life at the London Hospital when about
eighteen years old, and he qualified as M.R.C.S. four years later.
From this time forwards he was self-supporting. I have lately heard
from a distinguished surgeon, who was Surgical Registrar at the Hospital
when Mercier was House-Surgeon, that he was looked upon as exception¬
ally bright and thoughtful, giving promise of intellectual achievements
of no common order, and that when in after years he renewed his
acquaintance with Mercier, he “marvelled greatly at his wide know¬
ledge of all sorts of subjects outside his professional work: general
literature, mechanics, agriculture, etc.” He adds, “I loved him, admired
him, and read everything written by him.”

At the London Hospital Mercier came especially under the influence
of Dr. Hughlings Jackson, and thus was led to study deeply the writings
of Herbert Spencer which greatly inspired Jackson’s thought and
work. Mercier was one of but two men I have known who read through
twice and carefully studied the whole of Spencer’s volumes. Knowledge
of this rare feat must have kindled even that calm philosopher’s enthu¬
siasm. It was no' long time before Mercier’s natural bent towards
scientific thought and philosophy became fixed, and, as might have been

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expected, he devoted himself especially to his favourite studies and took
to alienism as his profession. After serving as a medical officer in some
large public asylums, he was, on the recommendation of Sir James
Crichton-Browne, appointed as resident physician to a private institu¬
tion which was in need of thorough reconstruction. Under his auspices
the institution was energetically reformed, removed from London to
Catford, in Kent, and carried on by him successfully for many years
until failing health obliged him to resign. For a few years he practised
in London, and finally went to Parkstone in Dorsetshire, where he
took private' patients until a few years before his death.

During a period of over twenty years he suffered severely from the
pains and the progressive crippledom of osteitis deformans. In his later
years he was attacked by a deafness that at last was nearly total, and in
course of time by choroiditis, which for many months before his death
put a stop to reading and writing. He began, however, to write by
dictation, and persevered until a sharp onset of gout in the foot
followed promptly by diaphragmatic pleurisy was his almost sudden
death-blow; for his chest had for long stopped its breath-work.

Until about the last eight years, spent at Parkstone, Mercier held
many appointments, and did much public work of value. He was
Lecturer on Insanity at Westminster Hospital School of Medicine for
many years as well as at the London School of Medicine for Women ;
and later he held a similar post at Charing Cross Hospital, where he
was also Physician for Mental Diseases. At the London University he
was examiner on this subject. As a member of the Departmental
Committee on the Treatment of Inebriety, appointed by the Home
Secretary in 1908, he did good service, contributing in large measure to
the Report ; and his evidence given before the Royal Commission on the
Care and Control of the Feeble-minded on behalf of the Royal College
of Physicians was of considerable importance. His sound knowledge
and rare power of expressing himself with precision of language gained
him much credit when giving evidence in the Law Courts, and he was
for many years a prominent and welcome speaker at the Medico-Legal
Society. Mercier was also appointed by the College of Physicians to
deliver the Fitzpatrick Lectures on the History of Medicine in 1913
and 1914, his subjects being “Astrology in Medicine” and “Leper
Houses and Mediaeval Hospitals.”

It is needless for me to recite here any particulars of Dr. Mercier’s
long service and activity in connection with this Journal and the
Association, but I would call to remembrance the address he gave in his
year of Presidency, which was a very striking and thoughtful account of
his own attitude at that time towards the questions underlying the
problem of the relation between body and mind.

He was married a second time after an interval of several years.

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and had the grievous fate to lose, only a few years before his death, the
much-loved wife to whom he had been married but two years.

In reviewing here the special qualities of Dr. Mercier as an alienist,
a scientific philosopher and a man of letters, I cannot attempt any
detailed or even adequate criticism of his numerous and varied works.
I have already indicated my judgment of him as an alienist physician
and teacher, and do not propose to speak much further under this head
in a journal among whose readers there are many more fitted than
myself to deal comprehensively with this part of the subject. But as I
am impressed with the belief that Mercier has been from time to
time more or less misunderstood, and therefore misrepresented, in
respect to one matter which seems to me of importance, I shall make a
brief endeavour to lessen or dispel the misunderstanding to which I
refer. I gather from what I have heard at some meetings of the
Association and have read long ago in medical journals, that from the
early time when Mercier began to insist on the primary importance of
concentrating on disorder of conduct in the diagnosis and interpretation
of insanity, he was frequently understood and quoted as meaning that
disorder of conduct was the primary pathological event in point of time
that ultimately led up to the diseased state known as insanity. In other
words it seems to have been sometimes implied that Mercier looked
upon disease of the mind as a result of disorder of conduct.

I am well aware that occasionally in the course of controversial
correspondence Mercier did not re-state in full the definition of insanity
which he had frequently reiterated in his writings and had persistently
set forth, as disorder of conduct always connoting disorder of mind and
brain and other organs. And when, on one of the occasions mentioned
above, he replied to his critic, “ When I say that insanity is primarily a
disorder, not of mind, but of conduct, I intend to state my doctrine,
not of conduct, but of insanity,” it is perhaps not very surprising that
his meaning, however clear it must have been to most readers, might
be somewhat obscure to others who were imperfectly acquainted with
Mercier’s previous writings, or had not taken the trouble to find out the
real point at issue.

However this may be, it is very plain even in his early writings that
he was insisting on the fact that disorder of mind could and did exist
without insanity; that disorder of conduct is of the first importance as
a sign of insanity, and often the sole sign, its accompaniments being
matters of inference only or mainly. Mercier, in a word, taught that a
man is rightly judged as insane from evidence of what he says and does,
not of what one may infer or guess that he thinks or feels.

As to how far Mercier’s teaching on this matter was original or not
mere opinions may differ. This question cannot be discussed here.
It appears to me, however, that at first he was criticised, not for talking

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platitudes, but for holding erroneous views; but that in later years, and
after his own reiterated statements that his views had not been accepted,
it was argued that, on the contrary, his views were common property
and required no assistance to recommend them. For myself I cannot
avoid the conclusion, based on the grounds above stated, that Mercier
was in this instance, as in all others, very far from thinking or even
talking platitudes when he issued his first work on insanity, and I feel
sure that genuine misconception on the part of some of his hearers
and his readers must have given rise to the question of the importance
and originality of his teaching in this respect. It is of course only
this last-named question which really concerns this memorial notice;
and as, in common with many others, I hold the view that this part of
Mercier’s exposition of the scientific study of insanity is both original
and light-giving in a very notable degree, I have deemed it right to give
my own notion of this matter. Mercier was doubtless an eager disputant
on many questions of varying importance, when no point of scientific
moment was concerned, and sometimes plunged into controversy for
the mere pleasure of it. On such occasions he often allowed his
abundant wit and humour to have full play; and though in most of his
serious writings this tendency was duly restrained, it may have been
sometimes apparent in a context which rendered it liable to misinterpre¬
tation. But the bulk of his important works bears the true marks of
careful observation and sound reasoning, and demonstrates his single
aim to search out the truth in all questions into which he inquired.

As a philosophical student of scientific matters, especially in the
sphere of Psychology , Mercier’s rank was confessedly high. Yet he is
not readily classed as an adherent of any special school or 'ism. During
most of his life he was strongly influenced by the biological and psycho¬
logical tenets of Herbert Spencer. Thus he continued to hold, long
after the time when the work of Weismann and other biologists had
shown grounds for rejecting it, the doctrine of the strictly biological
transmission to offspring of characters specially developed in the life¬
time of parents. And his psychological writings, especially in their theo¬
retical aspect, were, like Maudsley’s, more or less coloured by these
views on questions of heredity and reproduction. But later in life he
became increasingly inclined to recognise more fully the part played
by training and experience, especially as regards the human mental
qualities, in the development of characters, and to regard all alike as
the joint product of a transmitted germinal tendency and of environ¬
mental action.

On the more speculative, but, with regard to the scientific study of
psychology, the more relevant question of the relation between bodily
and mental functioning, Dr. Mercier was, at least until his later years,
a confessed “dualist”or “epiphenomenalist,” and taught, with Spencer

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and others, one doctrine of an “impassable gulf” between so-called
“ mind ” and so-called “ matter.” (*)

Yet even on this much-debated question there were, I think, a few signs
in Mercier’s later writings and perhaps more in what he said in the
course of discussion, of his inclination towards the views which he had
formerly opposed. At any rate, Mercier was no blind follower of any
authority. He was an independent thinker, far more ready to modify
or abandon his opinions than some of his critics have supposed.

In noticing some of the most important of Mercier’s many other
books I must confine myself to mere indication of what I deem to be
their merits, without attempting any critical review.

His earlier work on the Nervous System and the Mind, which preceded
by several years his later and more widely known treatise on Psychology ,
Normal and Morbid, may still be regarded as a valuable exposition of
the subject, in which no one of any school of thought is likely to find
much cause for quarrel. It is especially adapted for readers beginning
their studies.

Much the same may be said of the book on Conduct and its Disorders ,
Biologically Considered', in which the author estimates the various
modes and phases of human activity in the light of their value in secur¬
ing the survival of man in the struggle for existence. This book is
complementary to several others of Mercier’s works, and, though open
to criticism from some biological points of view, must take a high place
for its originality and practical value. It bears the mark of much study
and close thinking.

The work entitled A New Logic consists of a detailed criticism of
both traditional and modern logic as taught in professional lectures and
treatises, as well as of an insistent setting forth of the distinction
between the “material” argument on which action depends and by which
discovery is made, and the forming logic of postulation, in which the
proposition is formulated for the purpose of the argument. The book
has met with more blame than favour from specialists in logic, to some
extent apparently on the ground of the author’s alleged misunderstand¬
ing of the Aristotelian logic. I cannot venture to enter even into the
precincts of the modern logical arena, but will say only that at least the
constructive part of this book, on the science and art of reasoning, seems
to me of the highest worth to all intelligent students who desire to learn
how to think correctly. Much of its contents may be read with advan¬
tage in connection with the author’s book on Causation, presently to
be mentioned, in which there will be found an acute criticism on
J. S. Mills’ Canons of Induction , and also Mills’ whole treatment of
“ Causation.”

Mercier’s book on Causation and Belief, which of all his more
especially philsophical works I rank the highest in respect of sound

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thinking, clear expression and practical value, must be passed over here
without any justification of my opinion of it. It appeared first in this
Journal in January and April, 1916, and subsequently was published in
book form by Messrs. Longmans & Co. Such a book was greatly needed.
The thoroughly practical chapter on “ Causes of Death and Causes of
Insanity ” affords one out of many striking illustrations of the high value
of this book, and in itself may serve to contribute largely to the justifi¬
cation which space forbids me to attempt. The two books by Mercier
dealing with the legal and medical sides of the subject of crime and
criminals, entitled respectively Criminal Responsibility in the Insane
and Crime and Criminals , were both awarded (with an interval of ten
years) the Swimey Prize, which is given jointly by the Society of Arts
and the Royal College of Physicians for the best book on medical
jurisprudence. The first has been acclaimed widely by both legal and
medical authorities, and the second, in my judgment and that of many
others conversant with the subject, sets forth within comparatively small
compass one of the most comprehensive, careful and best-reasoned
expositions of the subject-matter with which I am acquainted. It is
written with truly scientific method and much knowledge of the material
dealt with. This work is destined to outlive for an indefinite time the
immense majority of all others devoted to the consideration of the
nature of crime and criminals.

A few more books, minor in point of size although not all of them in
relative importance, are well worthy of note. In his later years Mercier
took up strongly the subject of “modern spiritualism” and “telepathy,"
which he had hitherto deemed too insignificant for serious handling;
but, on the appearance of Sir Oliver Lodge’s reiterated announcement,
in the book entitled Raymond. , that the facts alleged in evidence of
spiritualism had been proved scientifically, he proceeded to make a
careful study of the material published over a space of many years by
many writers on both sides of this question, including the Reports of
the Society for Psychical Research. Thereafter he wrote a book called
Spiritualism and Sir Oliver Lodge. This thorough and brilliant exami¬
nation of Sir O. Lodge’s method of inquiry and the complete confutation
of the claim he made for scientific proof of his conclusions was followed
not long afterwards by an inimitably close parody of the spiritualistic
reasonings of Sir Oliver Lodge and others, with the title of Spirit Experi¬
ences, to which as a sub-title the publisher added, Or the Conversion of a
Sceptic. This contained numerous references to the doings of “ mediums,”
well known and widely advertised in spiritualistic writings, and was
aptly complementary to Mercier’s previous counterblast to the
Professor’s book. But the pamphlet seems to have grievously misled
several “ spiritualists ” and believers in “ telepathy,” as well as other
reviewers, the former welcoming the author as a deserter from “ ortho-

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dox ” science to their own ranks, and some of the latter deploring the
mental breakdown that could alone, as they deemed, account for this
great lapse of a “ distinguished scientist.” This jeu desprit cannot fail
to call to the minds of some of us an occasion when Mercier ventured to
read a paper before the Medico-Psychological Association on the Inter¬
pretation of Dreams, when his subtle parabolic essay was at first mis¬
construed by some, but at last, as its meaning appeared, brought down
upon the reader some measure of disapproval for its ill-placed levity.

To speak duly of Mercier as a man of letters is beyond my present
scope. His style varied considerably with his subject-matter, but it
was ever noticeable for its pure, unpretentious and incisive English.
He wrote with great rapidity; but in his larger works, and indeed most
others, he pruned and corrected much, frequently re-writing them in
part and sometimes wholly. In his choice of the right word, for the
sake of both accurate expression and literary form, he may be held to
have rivalled such masters of writercraft as R. L. Stevenson and
Flaubert. But under the easy and clear flow of his sentences the
linguistic precisian that he really was lay very deeply hidden.

Before ending this attempt to estimate the qualities of Dr. Mercier I
venture to give the following quotations, the one from an appreciation
kindly sent me by a literary friend of his and mine, Mr. Herbert
Allport, the other from a short notice of him written by Sir William
Osier, and published in the British Medical Journal in September,
1919.

Mr. Allport, who is the Secretary of an old-established club known
as “ The Casual,” which meets for frequent informal discussions on all
kinds of subjects, and of which Mercier was for many years one of the
brightest members, writes thus : “ There was no man of letters whom
Mercier loved better than Dr. Johnson, and there was no man whose
sayings he quoted more frequently. He had much in common with his
hero : the same fearlessness in controversy, the same sturdy common
sense, the same trenchancy of expression, the same wide and varied know¬
ledge, the same pugnacity, and sometimes, perhaps, the same disposi¬
tion to talk for victory . . . Whenever I was in straits for a paper at

the Casual Club I used to write to him for help. By return of post he
answered — 1 You can put me down for any date you like.’ He
might almost have added, 4 for any subject you like,' for there were few
with which he was not able and willing to deal . . . Usually, when

a man asks you for criticism it means that he is asking you for praise.
Mercier not only accepted criticism with the readiest good humour, but
was always willing to modify what he had written if he thought you had
made out your point . . . He wrote many books on many subjects,

and the subjects, within certain limits, modified the style. There were,
however, three characteristics which were never absent. The first

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and most important was the lucidity of thought and expression. The
second was the purity of the English. The third, which I have not seen
mentioned elsewhere, was the abundance and felicity of the examples and
illustrations. A fourth characteristic—the humour and sarcasm which
distinguished him—was less uniformly manifested; but whether they
were rigidly held in check or displayed with freedom, humour and
sarcasm were always at his command. Mercier was the most many-
sided man whom I have known with intimacy, and probably everyone
who came in close contact with him could contribute some fresh trait
of intellect or character. His knowledge of general history and
literature was astonishing in one whose attention had been chiefly given
to other studies. He had a few minor foibles, but there was no one
whom 1 admired so greatly, and I shall always be proud that he was
willing to regard me as a friend.”

Sir William Osier writes thus of Mercier: “ Though not of Oxford,
and a sharp critic of her methods, the University had a great fascination
for him, and of late years he not infrequently would spend a few days
at the Randolph seeing old friends. It was a rare treat to have him
dine in Hall, and afterwards, in Common Room, start a discussion on
the need of reform in our methods of education. He had very clear
and sound views, and argued with great ability upon the uselessness of
logic as at present taught. He delighted to shock the classical don
by unmeasured abuse of Aristotle, whose methods, he claimed, had done
irreparable damage to the human mind. With a rich vocabulary and
a keen wit he had no equal among us as a controversialist. He
was best with a few friends after dinner, with enough port, as he would
say, to quiet his gout. When last with me, a few months ago, he was
in fine form—I never saw such a triumph of mind over matter—and
entertained us with stories of his student life and anecdotes of
Hughlings Jackson and Jonathan Hutchinson. Maitre Francois must
have been a man of this type, and Mercier’s trick of tongue was racial.
Controversy he loved, and, strange to say, it brought him friends;
despite the caustic pen, he had a warm, generous heart. The courage
with which he bore his many infirmities is a lesson to us all. Never
complaining, he worked on to the end, and went down, as he promised,
with all the 1 flags flying.’ We shall miss the brilliant critic of our ways
and words.”

I would add but little on my own account to the words of these
discerning critics. However, on some occasions, Mercier’s readiness
to engage in controversy and his great joy of battle may have brought
him into sharp conflict of wit with some who misunderstood him, and
others who disagreed with his views know that he was a man innocent
of all rancour.(*) He never nursed a grudge, and always assumed that
those with whom he disputed were as ready as he was himself to take

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impersonally the passes and hits of argumentative encounters. In this
assumption, however, he was occasionally mistaken, and perhaps he
was sometimes himself to blame for being misunderstood. He may
have had some enemies, but he numbered troops of friends. He was
straightforward, fearless, warm-hearted and ever trustworthy. His
abounding courage inspired him to fight down depression in many
seasons of great trouble, and throughout that period of more than
twenty years when his life might be truly called “ a long disease.”

Among several able and untiring workers I have personally known
who bravely and cheerfully laboured on to the end there was but one
other whose many struggles, pains and sorrows could be fittingly matched
with his. He alone of them could have rightfully endorsed these
verses by that other who was the maker of them :

“ In the fell clutch of circumstance
I have not winced nor cried aloud,

Under the bludgeoning of chance
My head is bloody, but unbowed.

“ It matters not how strait the gate,

How charged with punishment the scroll,

I am the master of my fate ;

I am the captain of my soul.”

H. Bryan Donkin.

( l ) Here he differed widely from Maudsley, whose writings clearly show him to
have been a scientific materialist, and a direct successor, equipped with modern
physiological knowledge, to the French encyclopaedist philosophers, such as d’Hol-
bach and Cabanis; himself, it may be added, to be succeeded by Mr. Hugh Elliot,
the author of the newly-published and weighty book on Modern Science and
Materialism .—(*) As one instance out of several where strenuous scientific disputes
in journals led to subsequent acquaintance and ultimate friendship I would record
that one of the warmest of Mercier's opponents was appointed by him as his
literary executor.

Part I.—Original Articles.

The Need for Schools of Psychiatry. By C. Hubert Bond, D.Sc.,
M.D.Edin., F.R.C.P.Lond., Commissioner of the Board of Control
and Emeritus Lecturer in Psychiatry at the Middlesex Hospital
Medical School.

In their fourth Annual Report, published in 1918, the Board of
Control drew attention—not for the first time, but in more extended
form than hitherto—to deficiencies in the arrangements, as at present
organised, for the treatment of persons suffering from mental disorder.

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I I

especially in its incipient and early stages; to the insufficiency of
attention paid at medical schools ( 1 ) to this important branch of medical
science with its consequent ill-effects both to patients and to the
medical profession; and to the absence of any special qualification in
psychiatry, as a requirement for the higher medical posts in public
institutions for the insane, such as is demanded in public health of
medical officers of health of areas of above a stated size.

That these deficiences could not be made good without amendment
of the existing law was recognised, and accordingly a series of
recommendations in this direction were included in the report. As
some of these are sub judice , it is not proposed on this occasion to refer
to them, or, other than by way of their desirability as at least adjuncts
in a school of psychiatry, to the establishment of clinics for mental
as well as other neurological cases (including beds as well as an out¬
patient department).

(A) Clinics.

(i) Their Necessity for Mental Cases.

With respect to these clinics, it is, however, submitted that, whether
as independent units or—and, it is suggested, preferably—at or closely
affiliated with general hospitals, they should be regarded absolutely
indispensable as an integral part of the clinical facilities of every
medical school (a) if this branch of medicine is to be taught adequately
to its importance, both in the students’ curriculum and after qualifying
in medicine, and ( b ) if it is to receive study and research on organised
lines, without which progress cannot be other than intermittent and
spasmodic. A third reason (c) for their indispensability will be men¬
tioned a little later on.

The grounds of the hitherto prevailing disinclination of general
hospitals to shoulder this additional burden, quite apart from financial
considerations, are not difficult to understand, and, indeed, command
sympathy.( 9 ) But the significance of the mental element in diseases not
classified as of the nervous system—even in surgical affections—is
happily receiving increasing attention; and it is to be hoped that the
day is not far distant when no general hospital staff will be deemed
complete without a physician possessing expert knowledge in psychiatry:
especially is this the more probable, firstly as the necessity of specialism
becomes more admitted, and secondly, and by implication, as apprecia¬
tion grows of the advantage of all forms of expert knowledge being
readily available for each patient—in short, the benefit of what is
frequently referred to nowadays as “ team-work.”

If an interpolation will be pardoned, and though not part of my theme,
it may be remarked that consistency requires that this doctrine, once

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accepted, should be applied to the medical administration of all our
institutions for the insane; and that their arrangements should proride
that to the physicians of those institutions, regarding themselves as
primarily mental experts, and for consultation with them experts in
other branches should be available—not merely in emergency, but
as part of the routine consideration of at least the recent cases and
others in need of active treatment. This suggestion may savour of the
unattainable ideal, and so, indeed, having regard to the situation of
certain of the institutions, it must for a considerable time to come
probably remain; but, as respects a fair proportion of them, it could,
if desired, be attained even now—indeed, examples are not wanting
of partial attempts thereat.

(2) Their Affiliation with General Hospitals.

With that digression, let me return to and complete what, for the
purposes of this paper, is requisite to be said as to clinics to which
mental cases are admitted. The third reason for their necessity and—
as is now submitted— for their affiliation with general hospitals is ( c ) the
reluctance of sufferers from premonitory and early symptoms of mental
breakdown either to present themselves for advice at the out-patient
department of, or submit themselves to treatment in, a hospital, which—
res ipsa loquitur —labels the patient as the subject of a nervous or mental
ailment. Perhaps some day, when our profession is more skilled in the
differential diagnosis of the forms of mental disorder, can with greater
precision assert what these and those premonitory symptoms signify, and
can offer encouragement with the voice of certainty, an end will be made
of this prejudice, which at present is moreover only too often stimulated
by attempts to draw minatory inferences from misleading and ill-digested
statistics of heredity. Till that day arrives, the most promising hope of
breaking what in reality is a vicious circle of obstacles to treatment and
advancement of knowledge in the subject is an invitation and welcome
from general hospitals to all persons so suffering, coupled with adequate
arrangements, reasonably limited as to extent, for the in-patient treatment
of severer but recoverable mental cases. There is abundant evidence
that such persons, either at their own initiative or by the action of their
friends, are willing to go for treatment to a hospital that is general in
its medical functions; for they realise that privacy as to the nature of
the ailment is possible, and that the prejudice they fear need not be
aroused. Arrangements for out-patients .—Out of these arguments arises
my strong opinion that, to attain the fullest measure of success, the
out-patient department of such a clinic should not be at the clinic but
should form one of the sections, and be manifestly a part of the
general out-patient department of the hospital.

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1 3

BY C. HUBERT BOND, D.SC.

(3) Their Relation to- Other Clinical Units.

Furthermore, and to complete the picture as to the position a clinic
admitting mental cases should occupy in the clinical arrangements of a
medical school and as an integrant of a school of psychiatry, its structural
and other needs—about which I should like to say something on another
occasion—practically demand that it should be somewhat if not entirely
an entity. On the score of prejudice, that necessity imports a danger
which, if possible, should be avoided. Here, again, probably the most
promising method is to take advantage of the policy proposed or being
pursued by several general hospitals towards meeting their needs for
extension; whereby, in lieu of attempting to enlarge the existing
structure, arrangements are made to treat certain types of patients in
separate units erected on a site where land is liberally available—their
administration forming part of that of the parent building with which,
by the latter’s name being extended to them, their identity is maintained.

Clearly the mental clinic, as respects in-patient treatment, should
form one of these units. To this effect definite proposals have been
made and schemes are in preparation. To cite them might be
premature; but if any present here this afternoon feel at liberty to do
so, more specific information than can be found in my remarks would
doubtless be an encouragement elsewhere.

If yet one other interpolation is permissible, and before passing from
the question of these clinics for mental cases, it is my desire to enter a
friendly but strong protest against a readiness on the part of some of those
who welcome the advent of these clinics to relegate existing institutions
for the insane—truly not without an expression of regret—to the
role of providing for the care and nursing of irrecoverable cases: if
rightly understood, verily a noble duty calling 'out great qualities and
demanding much self-sacrifice; but such a divorce from incentive to
treat to recovery would be medically depressing to an extreme degree,
and would cause these institutions to be pervaded with a most prejudicial
feeling of helplessness. It is scarcely necessary to labour the point, as
it is most unlikely that the clinics, whether as parts of medical schools
or scattered more widely, will ever be able to meet the needs of all
recent cases requiring asylum treatment and of all those that are in
point of fact recoverable.

(4) Their Functions in Relation to Mental Cases.

On the other hand, these clinics, as respects their provision for
mental cases, should aim at fulfilling three main functions, and should
afford—

(1) Therapeutic facilities (a) for that proportion of recent and recover¬
able cases (whether certifiable or not, but not certified) upon whom

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existing arrangements press most hardly, and (£), in their section of the
general out-patient department, for incipient uncertifiable cases and for
certifiable cases in their early stages, so many of whom, through lack
of treatment, have to face life’s difficulties with a continuous feeling of
self-insufficiency.

(2) Better educational facilities during the medical curriculum,

enabling the student constantly to appreciate the relationship between
psychological and general medicine; but even these facilities will be
incomplete without the clinical material of the neighbouring public
asylum, between which and any school of psychiatry it is most important
that there should certainly be always a close link; and-

(3) A centre for both laboratory and clinical research and post¬
graduate study, for without these such a school must be barren.

If they can successfully make these provisions they will abundantly
fulfil the brightest hopes that can reasonably be entertained of them.
Per contra, without their establishment and, as I believe, without their
affiliation to general hospitals,,a number, difficult to estimate but by no
means negligible, of persons, the subject of various neuroses and mental
ailments, will continue untreated to carry on their daily tasks to their
own dissatisfaction and to the detriment of themselves and society.

(B) Diplomas in Psychological Medicine.

(1) Their Institution , 1908-12.

Most of us here to-day must have a lively recollection of the stimula¬
ting effect of the paper ( s ) read at the May Quarterly Meeting in 1908
by Lieut.-Col. D. G. Thomson. In it he laid bare the position and
powerfully advocated a series of measures, including the establishment
of diplomas, to combat the absence in this country of an adequate
scheme of instruction in the institutes and practice of psychiatry. The
movement that ensued is so closely associated with his name that it is
only with diffidence that another can take up its threads; and though
his goodwill has been secured in advance, my intervention is only the
result of representations that now, at the end of a decade since the
initiation of the proposals, a stocktaking of progress is due, that the
time is ripe for further representations to the bodies concerned and
of an assurance from the Secretary that this communication on the
subject will be welcome.

It will also be recalled that Col. Thomson’s paper, and a resolution ( 4 )
which he moved at the annual meeting in the same year, led to the
appointment of a sub-committee (*) of the Educational Committee to
consider the matter in detail; and that ultimately a highly important
circular letter, (*) signed by the then President, the late Dr. Mercier,
was forwarded to each of the Universities and other medical examining

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1920.]

bodies in the United Kingdom. In making their recommendations,
the Association formulated a carefully-considered syllabus of instruc¬
tional courses which, it was suggested, should lead up to the establishment
of diplomas in psychiatry.

Within the ensuing two years gratifying action was taken by five of
the Universities—Manchester, Leeds, Edinburgh, Cambridge and
Durham—each of which, in the order enumerated, passed regulations
for a diploma after attendance on approved courses and examination in
prescribed subjects. A perusal of these five sets of regulations shows
that the Association’s suggestions have been largely adopted; but
though they present many points of agreement, in several particulars
they differ considerably. In the hope that it may be of some service, a
summary of their similarities and differences is herewith appended. It
is not, however, intended to allude to these in any way seriatim , and
only in so far as it is desired to offer comments upon them.

(2) Obstacles to Progress.

That the action taken by these five Universities was a step of deep
import to our specialty no one will gainsay; and if its immediate results
have been meagre and perhaps disappointing to its authors—for, in
truth, less than a score of candidates have taken these diplomas—any
settled feeling of discouragement or disillusionment would be unjustified
and betoken ignorance of the facts. In the first place, the war caused
a partial if not entire cessation of the qualifying courses, and swept into
the naval and military services wellnigh all the men who might have
been tempted to proceed to one of these diplomas; and secondly, the
interval (from two to four years) between their institution and the out¬
break of war brought into prominence obstacles, from which—if the
truth is to be told and one may say so without offence—some lack of
enterprise and of appreciation of the responsibility incurred in attempt¬
ing to treat those mentally ill cannot be wholly excluded. But if in one
direction the war had a retarding influence, there is encouraging evidence
that in other ways it has had a quickening influence. It has taught us
many lessons: in our profession generally, the efficacy of special training
and of the real expert’s skill; in our particular branch of treatment, that
there is need of much more of the purely medical element; and above
all, the need to be up and doing and to give of our best. These are
lessons which inspire confidence that obstacles of a personal nature
need not be feared.

There are, however, difficulties connected with the circumstances in
which asylum physicians are placed (situation of the institution, need for
study-leave, uncertainty of prospects, etc.) which merit careful attention.
My colleagues, ever since the institution of these diplomas, have watched
the movement with interest and sympathy, and, impressed with its

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16 THE NEED FOR SCHOOLS OF PSYCHIATRY, [Jan.,

importance, the Board included in the recommendations already referred
to one to the effect that the possession of a diploma in mental diseases
should ultimately be obligatory upon tbe holders of the higher medical
posts on the staffs of institutions for the insane. In the meantime and
in the absence of any such enactment they have given further careful
consideration to the matter, and feeling that the remedy for at least
some of the principal difficulties is within the discretional powers of
Visiting Committees, the Board contemplate the issue of a circular
letter to those bodies. It would be improper to anticipate the details
of that letter; but, for the purposes of my argument, let us assume all
circumstantial difficulties can be and, with mutual goodwill, will be
removed.

(3) Their Scope, and Some Suggestions.

Upon the scope of the diplomas, especially as at least one of
them is under revision, it is desired to raise the following points for
consideration:

(1) As to their description, three of them are termed “—in Psycho¬
logical Medicine,” the other two being “—in Psychiatry.” It is very
doubtful if the latter term can now be deemed sufficiently wide in its
ambit; the former is probably to be preferred, and it moreover lends
itself to the use of the letters D.P.M. by way of abbreviation—a triviality
perhaps, but not without importance.

(2) It seems a pity that each does not lay down a minimum period,
subsequent to obtaining a registrable qualification, before which
the examination cannot be completed— e.g., two years.

(3) It is highly desirable that the regulations and syllabus of each
should plainly indicate the University term or terms during which each
course (whether systematic or practical) is available, with the days and
hours sufficiently set out to enable candidates to ascertain their ability
to attend.

(4) A statement, clearer than is always to be found, would be
appreciated as to the minimum extent to which the whole curriculum for
the diploma must be attended at the University in question. This can
be expressed as so many of the total number of terms required for the
full curriculum, or as so many courses out of the total number of subjects
(the plan already adopted in two instances), or in the alternative. Two
of the five Universities do not apparently insist on any local attendance.
If criticism is permissible, this latitude, though not without its con¬
venience in existing circumstances, seems to be regrettable, as the associa¬
tion of the University’s name invites the assumption that at least some
important share of the diplomate’s knowledge is the fruit of a school of
thought with traditions of its own. Should a diploma in psychological

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BY C. HUBERT BOND, D.SC.

I 7

medicine be ultimately obtainable at all our Universities, and especially
should their intramural arrangements permit of the development of a
school of psychiatry at each, perhaps this view will prevail.

(5) Another point upon which more precise information would be
helpful is the matter of fees for instructional courses. The fee for each
course should be stated, and it would be advantageous were a composition
fee quoted for the courses of Part I of the examination, another for
Part II, and a third for both Parts.

(6) The examination for each of the five diplomas is divided into

two parts, and the subjects, with some variation, fall under the following
eight heads : (a) Development and anatomy of the nervous system ;
(A) physiology, histology and chemistry of the nervous system ; (c)
pathology of the brain and nervous system, with post-mortem room and
laboratory technique; (d) bacteriology, in only two of the diplomas, and,
as respects one of them, limited to its relation to mental diseases—these
four heads are invariably comprised in Part I of the examination, as is
the next head in the case of one diploma; (<r) psychology, systematic
and experimental; (/) neurology; (^) psychiatry; and (A) clinical
psychiatry. It is suggested that in each of the diplomas Part II should
be reserved for the strictly professional subjects and that it should be
required to be passed as a whole; but that permission should be accorded
for candidates to present themselves in the subjects of Part I separately,
and also to be exempted from any subject of Part I in which they have
previously passed an examination of not less standard and scope. For
example, the latter concession might apply, as regards the anatomy and
physiology of the nervous system, to those who have passed the Primary
Examination for the Fellowship of the College of Surgeons of England ;
as regards bacteriology in its relation to mental diseases (where included),
to those who possess a degree or diploma in public health ; and as
regards psychology—which, under the suggestion as to the scope
of Part II, and probably more logically, would fall into Part I—to
graduates in arts or science for whose degree psychology has formed a
subject. It is further suggested as regards Part II that, besides psychiatry
and neurology, the tinid hcs come importance of knowledge

of psychopathology, the psycnneurqH and psychotherapy demands
the inclusion of these matters in *.» < : r rjulum and examination—a
view supported >• nurj by j . t T. H. Pear, of Manchester,

lately made to lec her.' ifl’psyc hiatry. and bj my former colleague Dr.
Bernard Hart in 1* coi .mumcation(') in connection with an inquiry into
“The Training of the Student of Medicine ” carried out by the Edinburgh
Pathological Club. The adoption of this suggestion should carry with it
recognition of clinical experience of the psychoneuroses, either as an
extra or in lieu of, say, three months of the time prescribed for clinical
instruction in psychiatry where that period extends to not less than a

LXVI. 2

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18 THE NEED FOR SCHOOLS OF PSYCHIATRY, [Jan.,

year; such recognition has already been sanctioned at one of the
Universities. Further, not, however, as an addition, but in order to
emphasise the principle that specialism should only be encouraged when
based upon a competent general knowledge, this opportunity is taken
to suggest that “ The relation of psychiatry to general and preventive
medicine ” should be specified as a sub-head in Part II.

(7) Lastly, the diplomas and instructional courses should, as seems
so far the case, be as freely accessible to medical women as to men.
Mention is only made of the point by way of emphasising the useful
sphere open to women as asylum physicians.

It would, however, be a mistake to dwell too insistently upon the
possession of this or that diploma; it is but a hall-mark. The really
important result to be attained is that, based upon a previous thoroughly
sound knowledge of general medicine, a prescribed course of instruction
shall have been followed, and that there shall have been acquisition of
knowledge not merely of facts memorised, but of principles which not
only render the holder at once more efficient, but which, by the force of
his awakened interest, result in his becoming a true student of his
special branch of medicine throughout his working years.

Our goal, therefore, should by no means be limited to repetitions of
courses of instruction leading to a diploma at certain or preferably at
each of the Universities. Rather should we urge that the importance
of the whole subject of mental health justifies and calls for, not merely
a colleague relationship between the several teachers in our diplomate’s
curriculum—some of whom may possibly belong to other Faculties in
the University than that of medicine—but a partnership so outwardly
and visibly manifest as to deserve the name of School of Psychiatry ;
and differences in tradition between such schools will be all to the
good.

(1) To Secure Instructional Courses and Opportunities for Continuation

Studies.

For such local consolidations of teaching activities the foundation
may be said to exist already at practiq|r.v every University. For
example, courses of anatomy and physiology on a standard for advanced
students are given yearly, and a few weeks of each of these two courses
are devoted to the nervous system. It may be that at present the
weeks covered by the anatomy of the nervous system do not coincide
with those given to the physiology of that system; but would the
rearrangement necessary to make them do so, and other similar adjust-
ments to enable the subjects of Part I of the Diploma (so far as they
may be said to comprise the institutes of psychiatry) to be taught

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BY C. HUBERT BOND, D.SC.

simultaneously, present serious difficulty or dislocate work in a manner
prejudicial to those taking the full courses? Inquiry at least might be
made, and, if the answer is in the negative, the road to the assistance
we want seems smooth—still more so when the number of teachers and
laboratory facilities are on a considerable scale. As regards Part II,
adjustments are probably not necessary; but lecturers in sufficient
number may not at once be available, especially if they are to be
properly remunerated.

But to overcome admitted difficulties, and to induce a correlation
of work on the part of a body of teachers whose duties and interests are
much wider than merely towards the sphere in which our interest lies,
demand reciprocity as expressed by a clear call for such assistance—
a call which, if limited to ambition to obtain a diploma, will be too
faint' to produce an effective echo. In other words, a correlation
and consolidation of work worth the name of school of psychiatry
(or neuro-psychiatry) connotes a bilateral contract that supply and
demand shall correspond, and an avowed intention to advance both
these complements.

(2) To Develop Schools of Psychiatry.

In the face of the knowledge of facts acquired in recent years as to
psychology in the abstract and mental health in the concrete, it is
inconceivable that a University will willingly be without such an organic
unit as is here meant by a school of psychiatry. Should we therefore not
see to it that support is not lacking from the periphery ? Is it too much
to ask that those who, by the responsibility they assume, profess expert
knowledge—be it in psychology, neurology or psychiatry (severally or
as a triad), and whether their responsibility extends to the abnormal
or to the maintenance of a watch on the mental development of normal
children ( 8 ), or whether they act as aids in the capacity of social service
workers—is it too much to expect them, collectively and individually,
to give active assistance in the development of such schools, and to
maintain a close working association with them ? It is fatally easy for
our professional work to slip into a groove which, followed, ends in
mental fog; and to dispel which, or prevent its rising, is there anything
more potent than a breath of the atmosphere of a progressively animated
University ?

Inconvenient distances and perhaps other difficulties at once present
themselves to our minds; but, if the situations of the institutions from
whose medical staffs this Association mainly recruits its members are
examined in relation to their proximity to the nearest University, it is
surprising, in the face of all that has at times been said as to the isolation
of their positions, to find how comparatively few there are, at least of those

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in England and Wales, which are not sufficiently near a University to
enable a reasonable number of hours—be they at a clinic, in laboratories,
in libraries or at discussions—to be put in and the journey to and fro
to be made on one day. Time so taken should count for grace, not
as neglect of official duties, so long as in fact they are not thereby
neglected, and not as part of needful recreation.

To be effective, such attendance and visits must be regular and form
part of a recognised scheme between the institutions grouped round
the particular University, and they take for granted—which is what we
may be sure the Universities would like us to do—their active goodwill
and co-operation. But before birth can be given to such a scheme—
and as left with you to day it is in very crude form—definite adherents
must be forthcoming, and it is because this Association is in the best
position, both to ascertain if a sufficient number of would-be adherents
exist and to put the scheme into better shape, that I have used this
opportunity( 9 ) to lay it tentatively before the meeting.

ADDENDUM.

Diplomas in Psychological Medicine.

Summary of Requirements of those now Existing.

Based upon suggestions made in 1908-9 by the Medico-Psychological Associa¬
tion—who still grant their own certificate in mental diseases which was established
in 1892, and has been taken by 370 medical practitioners—five of the Universities
in Great Britain have instituted and now grant a diploma in psychiatry or psycho¬
logical medicine, as indicated in the subjoined table.

Date of
institution.

University.

Designation of diploma.

19IO

Manchester

. Diploma in Psychological Medicine.

1911

Leeds

• »» » »»

19U

Edinburgh

,, Psychiatry.

1912

Cambridge

,, Psychological Medicine.

1912

Durham

,, Psychiatry.

While their regulations point to much similarity in their scope and examinations,
these five diplomas present several important differences, of which, and their simi¬
larities, the following is a summary :

(1) Age and medical standing .—No minimum age is prescribed by any of the
five Universities, and the diploma of each of them is open to all medical practitioners
whose names are on the medical register, except in the case of Leeds, whose diploma
is restricted to graduates in medicine (but not necessarily of Leeds) of one year’s
standing. Manchester and Cambridge require candidates to have attained a regis¬
trable qualification at least two years previously to their completing the examination
for the diploma, but both permit Part I of the two divisions, into which each of the
five Universities divide the examination, to be passed at any time after qualification.

(2) Duration of courses. —One academic year of three terms is ordained at
Manchester and Edinburgh; six months at Leeds; and, while no corresponding
period is specified at Cambridge and Durham, the latter University prescribes either
the length of each instruction course or the number of hours of work to be performed
(see (i) to (viii) below), and the former enjoins at least twelve months’ clinical
experience in an institution for the insane (see (vii) and (viii), and note (6) below).
At Durham, practitioners registered prior to the year 1911 are excused from
attendance on the courses of instruction specified for the diploma.

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(3) Attendance at the University granting the Diploma. —At Manchester two
of the requisite three terms must be spent at that University ; at Leeds a six months'
course of systematic instruction on the normal and morbijl anatomy and histology
of the brain must be pursued in the recognised laboratories of the University; at
Edinburgh attendance at the University on five of the prescribed eight courses is
obligatory; none is insisted upon at either Durham or Cambridge.

(4) Curriculum and examinations. —These comprise* in varying extent as
indicated, the following eight heads :

(i) Development and anatomy of the nervous system. —Manchester's require¬
ments are set out in the next paragraph; and for those of Leeds and Cambridge
see notes (a) and (6) below. By Edinburgh and Durham ten meetings of two
hours each are specified; the latter University indicates the standard as an
advanced one.

(ii) Physiology , histology and chemistry of the nervous system. —At Manchester
heads (i) and (ii) are grouped together and an approved course is required. The
requirements at Leeds and Cambridge are indicated in notes (a) and ( b ) below.
Thirty meetings, each of two hours' duration, are allotted by both Edinburgh and
Durham.

(iii) Pathology of the brain and nervous system , with post-mortem room and
laboratory technique. —At Manchester an approved course is required and for
Leeds and Cambridge see notes (a) and ( b) below. Edinburgh and Durham both
specify twenty meetings of two hours each.

(iv) Bacteriology. —Edinburgh limits the scope to its relation to mental diseases
in a three months' laboratory course of two or three hours daily. Durham requires
the same course of instruction as for its degree of Bachelor in Hygiene. The
other three Universities do not demand work in bacteriology further and subsequent
to that included in the general medical curriculum ; but as to Cambridge, see the
latter part of note (£).

(v) Psychology , systematic and experimental. —Instruction at an approved
course is required by Manchester and Leeds, qualified in the case of the latter by
especial reference to the symptomatology of mental diseases. A course of from
twenty-five to thirty hours is required by Edinburgh and Durham. At Cambridge
—ana see note (b) —this subject is included in Part I of the examination, whereas
at each of the other four Universities it is reserved for Part II.

(vi) Neurology. —A course of ten clinical demonstrations is prescribed by both
Durham and Edinburgh, the former limiting them to the rarer forms of nervous
disease and the latter regarding them as supplementary to the ordinary M.B.
course; and a course of clinical neurology is required by Manchester. Thus at
each of these three Universities emphasis is laid upon the clinical aspect of this
subject, but at Cambridge, while the duration of the course is not specified—see note
(£)-—a syllabus is laid down and there is a written as well as clinical and oral
examination in neurology. In the Leeds curriculum there is no specific reference
to neurology, reliance apparently being placed upon the courses under heads (i),
(ii) and (iii).

(vii) and (viii): Psychiatry and clinical psychiatry .—A six months' course of
instruction in psychiatry (systematic, clinical, medico-legal and asylum admini¬
stration) is prescribed by Manchester, but this course is apparently excused in the
case of those who have acted as resident medical officer in an asylum for one year
or for the two separate periods of six months. Leeds requires a six months’ course
in clinical psychiatry, asylum administration and the medico-legal aspects of
insanity, and residence in an asylum as clinical clerk or assistant medical officer for
six months, but the instructional course is excused where the candidate has been
an assistant medical officer for two years in an asylum with at least 500 beds.
Both Edinburgh and Durham require lectures in a course of ten hours supple¬
mentary to the course required for the M.B. degree, and both require instruction
in clinical psychiatry either in a course of six months given at a recognised
institution or in a course of three months, coupled with the holding of a resident
appointment for three months—both alternatives being subject to modification if
residence has extended to six months. Cambridge requires twelve months’ clinical
experience in a recognised institution, for which purpose special neurological
hospitals of over 40 beds, under either the War Office or Ministry of Pensions,
have recently been added to the list of places so recognised.

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Note (a).—The Leeds regulations do not lay down the length and scope of the
several courses required with as much particularity as generally elsewhere; but
there is a governing regulation prescribing, for all the subjects of examination for
the diploma, attendance on approved courses of instruction during six months at
least after graduation; it may also be noted that its regulations with respect to
heads (i), (ii) and (iii) refer specifically to the brain and not to the nervous system
in general.

Note (A).—The Cambridge regulations make no specific reference to attendance
at instructional courses, but wide powers to determine generally matters connected
with the examination are left to a managing committee nominated by the State-
Medicine Syndicate; and while schedules of the matters included under heads (i),

(ii) , (v) and (vi) are supplied, it is made clear that they are merely for guidance
and not to limit the scope of the examination, which is intended to test the
candidates’ theoretical and practical knowledge of every branch of psychological
medicine.

(5) Examinations. —As already indicated, each of the five Universities groups
the subjects it requires into two parts; each part forms one examination, and
Part I, except at Cambridge, must be passed prior to or at appearance for Part II.
Except at Cambridge, the subjects numbered (i), (ii), (iii) and, where required,
(iv) are comprised in Part I, and (v), (vi), (vii) and (viii) in Part II. At Cam¬
bridge Part I comprises subjects (i) r (ii) and (v), while Part II includes (vi), with

(iii) , (vii) and (viii).

(6) Fees for instruction. —It is not easy to ascertain them from the regulations
as respects Manchester, Leeds and Cambridge. A composition fee of 25 guineas
is payable at Durham and the total of the fees at Edinburgh amounts to about
18 guineas.

(7) Examination fees .—These amount to 10 guineas at Manchester, Edinburgh
and Durham, 5 guineas at Leeds and 12 guineas at Cambridge.

In addition to these five diplomas a diploma in mental diseases, open to
graduates in medicine, was instituted by the Royal University of Ireland in 1895 and
is still maintained by the National University. Particulars as to this diploma
will be found in the calendar for 1919 at pp. 120 and 264.

Several of the Universities in the United Kingdom recognise mental diseases
as a subject in which a candidate may specialise for the degree of doctor in
medicine. Notably psychological medicine is one of the departments in which
the degree of M.D. may be taken at the University of London. Mental disease
is also one of the special departments in which a candidate may exercise his choice
as to one of the three cases, upon which he must submit a written report and
commentary at the clinical part of the examination for the M.D. degree at the
four Scottish universities.

None of the colleges of physicians grants a diploma in psychological medicine,
notwithstanding that they all do so (conjointly with the corresponding college of
surgeons) in public health, and that one of them does so in tropical medicine.
The Royal College of Physicians of London, however, holds for its members (but
not for its licentiates) an examination in psychological medicine and permits the
fact of this having been passed to be endorsed on the membership diploma. At
the Royal College of Physicians of Edinburgh candidates for the membership are
required to pass an examination (1) on the principles and practice of medicine,
including therapeutics, and (2) on one of nine subjects—among which is psycho¬
logical medicine—to be selected by the candidate, in which a high standard of.
proficiency is expected. At the Royal Faculty of Physicians and Surgeons
of Glasgow the examination for the Fellowship comprises either medicine or
surgery and one, at the option of the candidate, of some thirteen subjects
or branches of surgery and medicine, among which is psychological medicine.
It may be of service to mention here that in the case of candidates who have
served in the recent war at home or abroad, it is possible during the ensuing five
years to secure the privilege of being examined for this Fellowship solely in psycho¬
logical medicine. At the Royal College of Physicians of Ireland candidates for the
membership are required to pass a general examination in medicine and pathology
and a special examination in one of three groups or in a group or subdivision of
medicine, which shall be judged to be equal in value to one of the specified
groups; and it is understood that the College, upon two months’ notice, are

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1920.] CASES WITH ENDOCRINE CONSIDERATIONS. 23

willing to consider the value of subjects submitted by a candidate who wishes to
specialise in psychological medicine.

While care has been taken to make this summary accurate, intending candidates
should, of course, consult the official regulations.

(*) See Lancet, April 6th, 1912, p. 934 ; ibid., June 21st, 1919, p. 1092 ; ibid.,
August 2nd, 1919.—(*) Journal of Mental Science , vol. lxi, 1915, p. I.—(*) Ibid.,
vol. liv, 1908, p. 550.—( 4 ) Ibid., vol. liv, 1908, pp. 791-3.—( 5 ) Ibid., vol. lv, 1909,
p. 757, and vol. lvi, 1910, p. 374.—(*) Ibid., vol. lvi, 1910, p. 373.—( 7 ) Edinburgh
Medical Journal, October, 1918.—( 8 ) See Lancet, April 27th, 1912, p. 1017; and
December 20th, 1919, p. 1167.—( 9 ) Quarterly Meeting of the Association, Novem¬
ber 25th, 1919.

Some Mental Cases with Endocrine Considerations. By Guy P. U.
Prior, M.R.C.S., L.R.C.P., Medical Superintendent, Mental
Hospital, Rydalmere; with Reports on Microscopical Findings by
S. Evan Jones, M.B., Medical Officer, Mental Hospital, Callan
Park, New South Wales.

It is well known that with the grosser lesions of many of the ductless
glands there are profound alterations in the subject’s mental powers.
There are doubtless many less pronounced mental alterations due to
slighter lesions of these glands which are for the most part unrecog¬
nised—in fact difference in character and disposition in different indi¬
viduals and in the same individual at different times may be due to the
variation in the balance of the internal secretions.

Those alterations due to lessened action of a gland have been brought
about experimentally by removing the gland in question, with con¬
stantly recurring results.

The mental changes due to over-secretion of a gland are not so well
understood, and the effect produced by prenatal or congenital gland
disease upon the cerebral development has hardly been studied.
Congenital thyroid disease in the form of myxcedema and cretinism
and the results of treatment with thyroid are known, but the effects of
early or congenital failure of the other glands are not, and it is possible
that the changes in the central nervous system caused by these may be
as far-reaching as those in thyroid failure. It is likely that early
changes in gland tissue may be a potent cause of imbecility. Many
an imbecile bears unmistakable signs of glandular dystrophy. An
Editorial article in Endocrinology refers to an unpublished paper, which
states that of r,ooo defective children 17 per cent, were recognised
as of endocrine origin (1). The same article also states that the Binet-
Simon age of defective children has been advanced many years after a
few months of treatment with thyroid or pituitary. It is possible that
there is a large class of ill-defined cases of want of endocrine balance
seriously affecting both physical and mental development, which, if

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capable of early diagnosis and treatment, might enable some imbeciles
to attain a fair, if not average, degree of intelligence.

The cases i, 2, 3, 4, 5, 8, 14, 15, 17, 18, 23, 26, 27, 28 and 29 of our
series are congenital or of early development, and show evidence of
glandular irregularity.

Their condition in the present state of knowledge cannot be diagnosed
until there is structural deformity or want of mental development. Did
it lend itself to an earlier diagnosis their future outlook might be very
different.

The glandular influence on physical development and structural
change is better understood than is its influence on the mental develop¬
ment. The large formation, with its increase in bone growth of
acromegala and its opposite condition of dystrophia adiposa genitalis,
is well known, as also is the difference in the conformation of a
myxoedemic and a case of Graves's disease. The changes in an animal
after castration, both in character and structure, and the eunuchoid
condition due to lack of secretion of the interstitial testicular cells, and
the changes in the secondary sex characters and the early sexual
development due to lesions of the suprarenal or pineal, present no
difficulty in recognition.

Feeding of Tadpoles and Guinea-pigs with Glandular

Extracts.

The tadpoles were taken from the pond when about two weeks old, and, as
near as possible, were selected of the same size. They were fed every morning with
a tabloid of the respective glands. They had no other food except bread-crumbs
and water-weed, but this was a mistake, as it would have been better to have given
them some animal food, as the controls received none, while the others did in the
gland. The fact that the controls did not develop detracts from the value of the
observations, but the results obtained from the gland-fed tadpoles, compared with
each other, may be of some interest. The tadpoles were taken on October 27th
and put into separate bowls, and fed upon thyroid, parathyroid, thymus, didymin,
suprarenal, anterior pituitary, and another lot received no gland.

Those fed upon thyroid were all dead by November 19th. They were extremely
small, in fact no bigger than on October 27th ; they had four legs, and their tails
were nearly absorbed before dying. Some day or two before they died they would
suffer from syncopal attacks, would swim very quickly round the bowl, suddenly
turn on their backs, and drop to the bottom of the water, where they would lie as
if dead for ten minutes or more, and then get up and repeat the performance.

Those fed on thymus were, on November 15th, four times as large as the
controls; one had hind legs, another none; they were pale in colour and trans¬
lucent. By December 12th three had died. One had changed into a frog and
escaped. The others were large tadpoles, with small hind legs ; their bodies were of
more triangular shape than those fed with other glands, and they were more
translucent. By January 12th three were still tadpoles with hind legs and no fore¬
legs. One had a haemorrhage into his abdominal cavity, and was so transparent
that his heart could be seen beating and his viscera could be distinguished. That
thyroid feeding hastened metamorphosis and retarded growth of tadpoles, and
that thymus has the reverse action, causing the tadpoles to become of abnormal
size, was pointed out by Gudernatsch (2).

Of the others, those fed with parathyroid remained very small, and by January

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P' IG. I .

F'lG. 2.

1. Control. 2. Parathyroid. 3. Thymus. 4. Didymin.

5. Suprarenal. 6. Anterior pituitary.

To illustrate paper by Mr. Guy P. L t . Prior.

A (Hard & Son Host Xo Ionian, f. id.

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12th there were still several tadpoles not much bigger than at the commencement.
One had become a small frog by December 18th, and died two days after. By
December 30th two more had become frogs, and were also very small, dying
almost immediately.

Those receiving didymin were the most inconsistent. Some had become frogs
by December 12th, and quickly escaped. By January 12th one was very large,
pale and translucent, and of the shape of those that had received thymus, and
others were darkly pigmented and with bind legs.

The suprarenal tadpoles were more forward with their legs than any of the
others except the thyroid, and were also darker in colour. They were of more
slender build and their limbs longer and finer than the anterior pituitary ones.

The anterior pituitary tadpoles showed the most definite changes, though these
were not uniform. On November 19th it was noted that they were much larger
than any of the others. On November 25th two were of extreme size, with very
long, thick tails, no legs, and their companions had small, thick legs and abnormally
large bodies. On December 18th five survived—three frogs and two tadpoles; these
latter were the largest and heaviest of the collection. The frogs were also larger
than the others, the legs being shorter and thicker and the skin markings more
distinct.

By the end of the time of our observations none of the controls had changed
into frogs, though some had hind legs. They were smaller and more backward
than any except the parathyroid, of which they were about three times the size.
The lack of animal food in their case may have kept them back. On December
18th the largest tadpole in each bowl was weighed, with the following results:
Control, 1,220 mg.; thymus, 3,330 mg.; parathyroid, 900 mg.; didymin, 2,320 mg.;
suprarenal, 4,106 mg.; anterior pituitary, 5,520 mg. Fig. 1, taken in January,
shows the relative size of the tadpoles at this time. Fig. 2, taken at the same
time, shows the most advancedly developed. It will be seen how much larger
the anterior pituitary tadpoles are than the others and the undeveloped condition
of those being, fed with parathyroid. It is, of course, impossible to draw any
definite conclusions from these observations, but they bear out the observations
already made upon thyroid and thymus feeding. It also seems that parathyroid
delays both metamorphosis and growth and that suprarenal stimulates both, but
without the far departure from normal caused by anterior pituitary, which stimu¬
lates growth and causes bone changes.

In reference to a paper by McCord and Allen on feeding tadpoles with pineal
gland they found a marked reaction of the pigment-cells, so that in thirty minutes
those of the pineal-fed tadpoles were much larger than the controls. (3)

We have also made feeding observations upon guinea-pigs. The does were fed
with the gland the day their young were born, the mothers being removed a week
later and the young continued to be fed with the gland for from five to six months,
their weight being taken weekly and the time of reproduction noted. Where
several guinea-pigs in the same pen have grown at about the same rate only one
is recorded ; where there has been much difference two are shown on the chart.
The controls steadily increased throughout. Those fed on thyroid lost weight
towards the end and never grew to the same degree as the controls, and were all
the time of thin, sickly appearance. One, when a month old, fractured a leg from
unknown cause, but disturbance of his calcium metabolism may have had some¬
thing to do with this. The parathyroids, for a time, remained stationary and at
one time lost weight, but at the finish were as heavy as the controls. Those fed
on thymus, whole pituitary, anterior pituitary and suprarenal developed about
normally except that the last two did not reach to within two or three ounces of
the controls. The pigs taking didymin were much inhibited and those taking
varium were inhibited to a lesser degree. In these two pens no buck was born;
the effect of the feeding applies only to does. A buck was put in with them when
they were a few weeks old, but as they were not fed from the first with the gland
a record of them was not kept. The pineal pigs grew very slowly for the first
five weeks, but by the twenty-second week were well up to the normal.

At the end of our observations the young guinea-pigs varied in age from
22 weeks to 28 weeks. They normally reproduce at from five to six months. (4)
Our control was 23 weeks old and was in young. The parathyroid had one
young when 22 weeks old, the whole pituitary one at 24 weeks, and the anterior

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pituitary one when 20 weeks old. The pineal doe at 25 weeks was heavy in
young. The pineal pigs had long, straight and silky hair such as we do not
remember seeing before in a guinea-pig, but we cannot say that this was the
result of feeding and not of breeding. In the thyroid at 22 weeks, thymus at
25 weeks, suprarenal at 23 weeks, didymin at 25 weeks and varium at 27 weeks
there was no pregnancy. It is stated that animals fed upon extracts of the glands
strike a fresh balance of glandular activity after a time and no great change is
brought about by such feeding. The results are also said to differ with the age
at which the animal is commenced to be fed.

The thyroid is the gland about which most is known as to its
relationship to the mind. A myxoedemic patient is depressed, dull,
slow in thought and action, with diminished reflexes, often with
hallucinations of hearing due to the swelling of the aural mucosa or
of central origin, and not rarely finds her way into a mental hospital,
where she is generally found to be a melancholic and irritable patient,
indifferent to her surroundings, idle and without interests, with a more
or less marked degree of dementia. Case 16, referred to in detail
later, was such a one.

In cases of hyperthyroidism there is the reverse mental picture.
She is often of cantankerous disposition and ever ready to take offence,
but she thinks and talks quickly, her movements are rapid, and her
energy abundant. Should she become insane, she generally suffers
from acute or subacute mania unless the condition passes from
hyper- to hypothyroidism, when the condition becomes one of melan¬
cholia.

Of the congenital mental conditions accompanying diseased states
of the thyroid we have cretinism—sporadic and endemic—Mongolism
and infantile myxoedema. With these there may be all degrees of weak-
mindedness—from the most extreme idiocy to a high-grade imbecile.
Mongolism is probably not entirely an athyroid condition and does not
improve to any extent with thyroid treatment, though Case 17 livened
up after receiving thyroid in small doses for some montjis, while her
hair-growth also improved somewhat.

Cretins and infantile myxcedemics make great improvement with
thyroid therapy. McCarrison records the case of a cretin, aet. 9,
who could neither walk nor talk, but who, after treatment with thyroid,
was able to walk, and learned to say a few words. (5) As a rule the
earlier the treatment is begun the better the result.

The mental symptoms of an adult myxoedemic are greatly improved,
if not cured, by taking thyroid. Hertoghe says that nerve-cells are not
destroyed in myxoedematous infiltration, but become infiltrated and
depressed, and that transmission of impulses, though delayed, is not
abolished. (6)

The thymus gland has some influence upon mentality. Sajous
states, “ Removal of the thymus in dogs is followed by clear evidences

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2 7

of idiocy (Morel). The thymus was present in all of 6i autopsies
performed by Katy on mentally normal children. In 28 mentally weak
children examined by Bourneville it was absent. In another series of
408 autopsies on non-myxoedematous children of from one to five years
of age the thymus was present in only 104 cases.” Sajous attributes
this to the presence of thymus being necessary for the proper carrying
out of the phosphorus metabolism, which is important for the develop¬
ment and maintenance in health of nerve-tissue. (7)

In our series of 46 post-mortem examinations from which the glands
had been taken for examination, 25 cases had a definite thymus gland.
Twenty-three of these were confirmed by microscopic examination, and
6 were not sectioned. Among these 46 cases were 32 epileptics, 22 of
these latter having the thymus present, of which 18 were sectioned and
examined with the microscope. The largest glands were found among
the epileptics. Eight epileptics were cases of sudden death, 7 being
under our care, while 1 of great interest was from a neighbouring
hospital, and at whose autopsy we were allowed to be present. All
these cases had enlarged thymuses. Two may be described as being as
large as the palm of the hand; of the others, one weighed 3} oz.,
another 2 oz., and a third i| oz. The youngest of these 8 patients was
20 years and the oldest 53 years. Two of them were found dead
at night, having been seen previously to within half-an-hour, and both
having been in their usual health the day before. One was Case 5, to
be described later under the apituitary cases, where a description of his
glands will be found. Case 31, the other patient who was found dead,
was of eunuchoid type, an imbecile and a sexual pervert, whose epilepsy
had commenced at 15 years of age, and who was 22 years at the time
of his death. He had a very large thymus, reported to be a persistent
infantile one, The suprarenal, both cortex and medulla, showed
degenerative changes.

Case 32 was set. 46. His epilepsy had commenced ten years
previously. He died immediately after taking a fit—the third within
eight hours. An attendant was standing beside him at the time. A
post-mortem examination was made, and the heart, lungs and kidneys
were found normal. There was a considerable amount of thymus
tissue, reported to be very vascular and of a regenerative type. The
suprarenals showed degenerative changes, both of cortex and medulla.
The thyroid showed vesicles small and irregular, the lining epithelium
cubical and actively proliferating. The intermedial tissue was increased
and the blood-vessels congested. The pituitary was in a condition of
over-activity. There was a small and normal parathyroid.

Case 33 was a girl, aet 25, an epileptic of ten years’ duration. She
did not have an epileptic attack on the day of her death, but after
going to bed became very restless, wandering about the dormitory. On

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being put back to bed by the nurse, for the third time, without any
resistance or struggling, she collapsed and died. An autopsy was
made nineteen hours after death. There was slight active tuberculosis
of both lungs. The heart was soft and flabby; the aorta was small,
admitting only one finger. There was thymus tissue present: it was
reported to be a retrogressive infantile one, and to contain numerous
Hassall’s corpuscles and also particles of lime. The ovaries were
fibrotic, and the vessels in process of obliteration. The spleen con¬
tained numerous small haemorrhages. The pancreatic cells were
shrunken and very few islets were to be seen. The suprarenals were
reported to be normal.

Cases 34, 35 and 36 all died shortly after taking a fit, and were
under different observations at the time of their death. Case 34 was a
man, aet. 20 ; was heard at night by an attendant to be in a fit, and was
in the convulsion when the attendant went to him, but died immediately
the convulsion had ceased. A post-mortem was made six hours after
death and there was venous engorgement of all organs. The thymus
was much enlarged. In this case also the aorta would only admit one
finger, otherwise the heart was normal. The report on his glands
stated that the thymus was of persistent infantile type, that the testes
showed interstitial fibrosis and diminished activity, that the thyroid
was quiescent, there was advanced vacuolation of the suprarenals, and
that the section of the pituitary showed an effusion of serum into
the pars intermedia.

Fig. 3 shows a thymus of infantile type. Note the dilated capillaries
and large Hassall’s corpuscles.

Fig. 4 shows a thymus of a regenerative type showing small masses of
fine thymic tissue containing Hassall’s corpuscles scattered through the
fatty areolar tissue.

Case 35 was set. 31 and had suffered from epilepsy since he was
twelve years of age. He had had five fits the night previous to his
death, and three on the afternoon on which he died, dying immediately
after the last. Before this he was conscious and fairly well. An
autopsy was held eighteen hours after he died. The heart was dilated, the
muscle being flabby; the aorta would admit two fingers through the
orifice from above. The thymus weighed 3J oz., the thyroid 1 oz. and
the spleen 6 oz. From the microscopical examination of the glands it
was stated that the thymus was a persistent infantile one, that the
testicles were normal, also the pituitary and spleen. The thyroid
was of increased, and the pancreas of diminished, activity. Of the
suprarenals, it was stated that the cortex showed advanced degeneration
and that the medulla stained normally, but was intensely congested.

Case 36 was a male patient, set. 53 years, 6 ft. 3^ in. in height, and
deficient in secondary sex characters. He had suffered from epilepsy

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normal. Including the 8 cases of sudden death, we have made post¬
mortem examinations and sections of some or all of the glands upon 32
epileptics, of which 20 were male patients and 12 female.

Of the male patients, 15 had enlarged thymuses, and in 5 the gland
was not present.

The suprarenals showed degenerative changes in 15 cases, were found
to be normal in 3, and in 2 they were not examined. The changes
in the suprarenals were mostly found and more marked in the cortex.
The cells of the cortex failed to stain, the nuclei stood out well, but the
cytoplasm was coarsely granular or represented by a fine network
enclosing clear spaces. In 4 cases the degenerative changes were well
marked in the medulla as well as in the cortex.

The testes from 4 patients were not examined; from 12 they were
found to be normal, and from 4 there was a deficiency in the interstitial
cells, one of these being Case 5—an apituitary one.

The pituitary showed no constant change in 11 cases ; it was either
normal or of slightly increased activity. In 5 cases it was not examined,
in 3 it was stated to be of diminished activity, and in 1 case, dying
suddenly, there was a serous effusion into the pars intermedia.

The thyroids were mostly of the two types, 6 being taken as being
quiescent and 7 as of over-activity. These we equally divided, there
being 7 of each in our series; in 4 cases the thyroid was normal, and
twice it was not examined.

The pineal was only examined twice. In one case it showed degenera¬
tive changes and in the other it was normal.

The liver was examined from 10 patients. Once it was found normal;
all the others showed signs of fatty degeneration or fatty infiltration.

The pancreas was reported upon from 8 patients. In 3 it was normal;
in the other 5 the islets of Langerhans were few in number and showed
degenerative changes.

The spleen was examined from 7 patients. From 1 case it was
reported normal, in 1 there were small haemorrhages, in 1 waxy degene¬
ration ; the rest showed fibrotic changes.

In the 12 female cases an enlarged thymus was found in 7 cases, the
condition being confirmed by the microscope in 6, in 1 case not being
sectioned. The gland was absent in 5 cases.

Of the ovaries, in 1 case these glands could not be found at the
post-mortem and were presumedly congenitally absent, in 3 cases they
were not examined, and in 8 cases the fibrous tissue was much increased
and the organs were shrunken and atrophic. In 3 instances small
Graafian follicles were seen.

The thyroid in 4 of the 12 cases was not sectioned; in 2 it was stated
to be normal, in 5 showing signs of over-activity, and in 1 case of under¬
activity.

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The pituitary was normal in 9 of the series, said to be of minus
activity in 1 case, and was not examined in two.

The suprarenals were normal in 5 cases, showed degenerative changes
in 6, and were not examined in one case.

The pancreas from 6 cases was examined. In 2 it was normal, and
in 4 the same degenerative changes were found as described in the male
cases.

The spleen from 4 patients was examined, 1 being normal; 2 showed
fibrotic changes and t was the subject of waxy degeneration.

The liver was examined from 9 patients. Once it was found normal;
the other 8 had fatty degeneration.

What strikes one as most worthy of note in these results is the large
percentage of cases in which the thymus is found to persist, and the
great number of times in which there is found degenerative changes
in the suprarenal cortex. That the liver, spleen and pancreas are
seldom reported to be normal is suggestive, but the number of times
these organs have been examined is not sufficient to say that changes
are constant. The fibrotic and atrophied ovary appear to be almost
invariably present, and the fact, as we have shown, that the menstrual
function is most irregular in epileptics (9) may depend upon this.
A corresponding change is not found to the same persistency in the
male sex gland.

Kajima describes similar ovarian changes as we have found in
epileptics in two cases of dementia prsecox, but he found no testicular
changes. (10) Writing on the Abderhalden reaction, Orton says that
the majority of dementia prsecox cases react against brain or sex-gland,
or the two combined, showing a dysfunction of this gland.(n)
Dr. Kate Hogg, in an unpublished paper written ten or twelve years ago,
claims to have found changes in the uterus or ovaries in 21 out of 30
cases of dementia prsecox examined. She came to this conclusion
from pelvic examinations made under an anaesthetic. She describes
the ovaries as being sometimes atrophic, sometimes subject to fibroid
degeneration, and sometimes as hypertrophied with loss of function.
She concludes the paper by saying, “ A condition exists which indicates
the unfitness of the organism to reproduce its like, which is the final
phase of degeneration.” It would appear from the condition of the
epileptics’ ovaries that also in them Nature is endeavouring to eliminate
the unfit.

Over-activity of the thymus has been described as causing eunuchoid-
like growth, ix ., tall individuals with long bodies and long limbs, and
deficient in secondary sex characters. Bandlier(i2) and Sajous(7)
both speak of an infantilism as being due, among other causes, to a
persistent thymus. Among our post-mortem cases, in which we have
found a large and active thymus, have been men of 6 ft. or over as Cases

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31, 36 and 38, the first 2 being of eunuchoid appearance, others being
of all degrees of size and weight, including two dwarfs as cases

5 and 18.

There are, in the series, three other cases not epileptics in whom an
enlarged thymus was found. Unfortunately only one of the three
glands was sectioned, this being from Case 18, which is described
under the cases; her thymus was a persistent infantile one. Of the
remaining two, one was from an imbecile lad of 18 years, who died
from pulmonary tuberculosis. His thymus weighed 2 drachms, thyroid

6 drachms, spleen 6 ozs., heart 8 oz., with an aorta that would only
admit one finger. The other was from an old lady set. 73, who died
from intestinal obstruction. Her adiposity was rather in excess, and
the hair on head and pubes very scanty. At the post-mortem a cyst of
the pituitary was found, the pineal and thyroid were small and some
thymus tissue was present.

Diminished suprarenal activity may be accompanied by mental
symptoms. Acephalic monsters are said to have no suprarenals. It is
stated in Osier and Macrae that “hypoplasia of the suprarenals”
has been noted in the hemicephaly and other failures of brain develop¬
ment. Czery reports absence of medulla in 5 cases of hydrocephalus,
and Hanseman 8 cases of anencephaly with atrophy. They described
the mental symptoms in Addison’s disease “ as a tendency to fatigue
from mental or physical exertion. Constant apathy associated with
depression, insomnia or an increased tendency to sleep. Yawning,
loss of memory, delirium, dizziness, tinnitus and headache.”(i3)
Falta says that in the later stages there may be delirium, convulsions
and coma.(i4) An over-action of the suprarenals in either sex is
manifest, by an increase in male sex characteristics and in the female
with amenorrhoea in addition.

“ Wiesel believes that the status thymico-lymphaticus is equal, or
almost equal, to the chromaffin tissue in the pathogenesis of Addison’s
disease. He suggests that adrenal inadequacy prevents the involution
of the thymus, the lymphatic glands undergo hyperplasia, the vascular
and genital systems hypoplasia.”(xs) If this is so it explains the
common association in epileptics of over-active thymus glands and
under-active ovaries and degenerative suprarenals.

Extracts of ductless glands of late have been found of service in a
wide variety of diseases and disorders. It is an extremely old method of
treatment. Harrower mentions Egyptian writings of about 500 b.c. in
which orchitic substance is advocated for the treatment of impotence.(i6)
Probably the first reference to organotherapy is in the Apocrypha,
where Tobias is commanded by an angel to take the heart, liver and
gall from a fish. The heart and liver were to be changed into smoke
and used as an inhalation for the purpose of driving away evil spirits.

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The gall was useful to anoint one who suffered from “ whiteness of the
eyes.”(17) This was written between 625 and 700 b.c., but it is our
purpose to limit our remarks upon the use of these glands to our own
experience, which has been mainly with epileptics and primary dements.
The glandular treatment of mental cases has its definite uses without
doubt, and it is certain that the scope of this usefulness will be greatly
extended with larger experience of their use. A patient may be not
far removed from idiocy, or apparently advanced in dementia, and may,
by appropriate administration of gland extracts, be rendered quite
unrecognisable from what he was, and who can say but that if treatment
could be undertaken much earlier, some congenital deficients might be
saved from being classed as such ?

We have found thymus useful in epilepsy in some cases, but, as in
all things in epilepsy, it appears harmful in others. One case, which has
been taking thymus for some years, averages many more fits if this is
suspended for a time, and takes some months to fully recover the ground
lost when the gland is resumed. Thymus causes a retention of calcium,
rol over the formation of acids, and is largely concerned
jgjffrtflthc ; ..-.phorus metabolism, by any of which means it may
\ influence epilfepsy. We have also found thymus useful, as regards both
k^ 0 exes|BHpe<; of increased sexual irritability ; here it probably acts by
I JjBjaHTovarian, thyroid, or pituitary secretion; an over-action of
of these will excite the sexual organs.

Thyroid, in addition to its well-known action in cases of athyroidism,
has been proved of extreme benefit in cases of primary dementia,
chiefly those of hebephrenic type. When given as advised by
Drs. Davidson and Johnson (18) —■*>., in rapidly increasing doses up
to 80 gr. per diem —remarkable results have been obtained. The
authors do not say how the changes come about and many of the cases
cured are certainly not of the athyroid type, and it is probably not the
thyroid per se that does the good. Thyroid is a stimulant to most of
the other glands, especially of the sex-gland, which has been shown
to be often of diminished activity in primary dementia ; it also stimu¬
lates the suprarenals and pituitary, and it is likely that in this way
the beneficial results are brought about. This mode of treatment
is not altogether safe, as it may light into activity an undetected and
unsuspected tubercular lesion. Smaller doses of thyroid combined with
suprarenal and perhaps sex-gland may in some cases bring about the
same result, as is instanced in Cases 14 and 21.

Suprarenal combined with thyroid has been of great use in the cases
just mentioned. We think the partial disappearance of the oedema
in Case 30 must be attributed.to adrenalin; the doses given were large
and long-continued and there were no persisting toxic symptoms. It
has been of value in some cases of epilepsy of asthenic type and in
LXVI. 3

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34 CASES WITH ENDOCRINE CONSIDERATIONS, [Jan.,

some old cases of alcoholic origin. It appeared to be of special value in
Case 61, who was a lad, aet. 9. Six years previously he had been
given a dose of diphtheria antitoxin because there was diphtheria in
the family. Two months later epileptic fits commenced; the attacks
for the first four or five years averaged from five to seven a week.
For eight months before admission he had from fifteen to forty attacks
daily—mostly minor ones—but had an occasional major attack. On
admission he was mentally fairly bright and he had several scars on the
back of his head from falls. He had a well-marked white demographic
reflex ; the hands and feet were bluish and cold, otherwise the physical
signs were normal. In the first month after admission he had 562 fits,
would lose consciousness and fall if not supported, but did not
often convulse. He was given suprarenal gr. v daily and bromide
and calcium. He had 303 attacks during the first month of treatment
and eleven during the second month and has had none since, now
twelve months. During the first three months he gained 14 lb. in
weight.

We have found parathyroid very useful in some epileptics and in
some its continued use seems necessary for their well-being. One of
our cases, while taking this together with bromide, had but one fit a
month, and without the parathyroid the number of fits rose to seven
or eight a month. This gland has proved useful in all cases of
myoclonic epilepsy in which we have used it

We have entered into the uses of pituitary when describing apituitary
epileptics, but we have not given it an extended use in other mental
cases. We gave it with calcium to two primary dements with pro¬
longed periods of amenorrhoea with the idea of stimulating the ovarian
function. One of these girls menstruated after a month’s treatment,
the other after several months. Both made considerable physical
improvement, but neither improved mentally.

We have had some cases of temporary—but no lasting—benefit
from varium and didymin.

Cases 1, 2,3 and 4 are all epileptic patients of apituitary type. Cases 1, 2,
and 4 are about 5 ft. 2 in. in height and weigh from 13 st. 11 lb. to 13 st. 8 lb.;
Case 3 is 5 ft. 5 in. in height and weighs 12 st. 9 lb. Cases 1, 2 and 3 show
deficient growth of body and face hair, their maxillary hair is absent or extremely
scanty, the hair about pubes is of effeminate formation and there is no hair growth
otherwise upon the body or limbs. In Case 4 there is a more abundant hair
growth both on face ana body. In all four the mammary glands are large and
pendulous, the hands and feet are rather small and clubbed, the genital organs are
undeveloped, the supra- and infraclavicular spaces are obliterated and the fat
distribution generally is as in the female. Their blood-pressure is rather low, the
highest in the standing position being 115 mm. Hg. in Case 1 and the lowest was
95 mm. Hg. in Case 2. In their dermographic reaction Case 1 gives no reaction ;
2 and 4 show a distinct white reflex, continuing for seven minutes in Case 2 and
for three and a-half minutes in Case 4.

Of their blood examinations Case 1 gives an average of 7,800 leucocytes per c.mm.,
with a differential count of polynuclear leucocytes 71 per cent., large mononuclear

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cells 5 per cent., small mononuclears 24 per cent., haemoglobin 90 per cent. Case 2
gave an average leucocyte count of 12,000, of which the polynuclear leucocytes
were 64 per cent., large mononuclears 5 per cent., and small mononuclears
31 per cent., a haemoglobin content of 80 per cent. Case 3, leucocytes averaged
11,300 per c.mm.; the polynuclear leucocytes were 74 per cent., large mononuclears
4 per cent., small mononuclears 22 per cent., haemoglobin content 80 per cent.
Case 4, leucocytes averaged 10,500 per c.mm., with polynuclears 76 per cent., large
mononuclears 8 per cent., and small mononuclears 16 per cent.

Falta, in describing the blood condition found in apituitarism, says
the red-cell count is slightly reduced and haemoglobin about normal.
Leucocyte count often reduced, sometimes increased. Of the differ¬
ential count he says that the neutrophilic cells are reduced and the
mononuclears, especially the small, are increased (19).

Cushing states that there is in these cases a low temperature, which
can be raised by an injection of pituitary extract (20).

In Cases 1 and 2 the temperature was taken twice daily for four days. In
Case 1 it varied between 97*4^ and 98*2° F. On the fifth day they both had an
injection of pituitrin. Four hours after the temperature in Case 1 registered 98*6° F.
The temperature of Case 2 varied between 97'4° and 98° F., the latter being
recorded only once. He rose to 98*2° F. four hours after the injection.

Although these four patients are by their general make-up and contour typical
of apituitarism, and the fact that they are epileptics rather bears out the diagnosis,
for this disease is often accompanied by epilepsy, the results of examinations of
their metabolic processes is not altogether consistent with this.

Falta says that in hypophysial dystrophy the carbohydrate assimila¬
tion limits are raised and that there is no inclination to glycosuria, but,
on the contrary, an abnormally high tolerance to carbohydrates; he
states that Cushing found an abnormally low amount of blood-sugar.
In two cases mentioned by Falta the amount of blood-sugar was
normal. He obtained no sugar urinary reaction after injections of
adrenalin (21).

Our tour cases gave a glycosuric reaction in their urine after an injection of
m x of adrenalin. On a second occasion Cases 1 and 3 were given an injection
of m v of adrenalin and their blood-sugar examined before and two and a-half
hours after the injection. Case 3 showed a trace of sugar in his urine before the
injection and a large amount after. His blood-sugar was *11 per cent, previous to
the injection and *14 per cent, two and a-half hours after, both being greater than
would be expected in a case of this type. Case 1 gave no urinary reaction to this
lesser dose of adrenalin, but his blood-sugar rose from ‘i to '12 per cent.

Case 3 was found to have a persistent glycosuria, which varies from a slight
trace to *37 per cent. His blood-sugar in ten estimations varied between ’13 and
*21 per cent. His glycosuria rose after a fit in all times observed but one. On
five examinations his urine was found to be free from sugar; on four occasions
this immediately preceded a fit, and the fifth time was after a fit. The changes
in his blood-sugar apparently bore no relationship to the epileptic attacks. His
general condition is good; he has no polyuria. Twenty-four-hour specimens
having been collected for fifty days, during which time the largest amount passed
being 1,278 c.c., there generally being in the twenty-four hours between 500 and
800 c.c., with a specific gravity in the neighbourhood of 1,020. No glandular
treatment influenced the daily quantity of sugar. He was given pancreatin under
the idea that the pancreatic secretion might be deficient; he also received pituitary
and thvroid without benefit to the glycosuria or epilepsy. The glycosuria is easily
controlled by diet.

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Case 5 was a case of similar kind except that he was more dwarfed and fatter,
showing the same physical conformation and very undeveloped genital organs.
He was at t. 28, and died suddenly shortly after taking a fit and without any
apparent cause that could have been thought sufficient to cause death. A post*
mortem examination was made about twelve hours after death. The brain showed
nothing appreciably abnormal, the sella turcica was ill-defined and shallow, the
pituitary body was very small, and the pineal gland was described as being small.
The heart was small and fatty, but showed no fatty infiltration. The abdomen, inside
and out, was very fat. The spleen, liver and pancreas appeared normal; both
kidneys were small and tabulated like that of a horse. A persistent thymus
gland was found in the midst of fatty tissue. Some of these glands were examined
microscopically, but unfortunately the pituitary was lost. The testicular inter¬
stitial cells were reported deficient, the thymus to be acutely congested and the
suprarenal to show signs of under-activity. The thyroid was normal.

Case 6 is one of interest on account of her history. She is a female patient,
at t. 18, is well nourished, with small hands and feet, smooth skin, hair smooth
but has been falling out for the last twelve months, pulse 80 per minute, blood-
pressure 115 mm. Hg. There is a tendency to hairiness on the lower limbs, and
on the abdomen there is a dark line from the umbilicus to pubis. The thyroid
gland is distinctly enlarged. She had convulsions in infancy; suffered from minor
epilepsy from five to fourteen years of age; at sixteen, at the time the menses
should have occurred, she had a major epileptic attack, and has suffered from
these at increasingly shorter intervals since. Menses appeared at twelve years of
age, was always irregular, but since the recurrence of the epilepsy the periods of
amenorrhcea have been longer, and sometimes persist for four months. If the
period does not occur somewhere about the proper time she has epileptic attacks,
which are preceded for about two days by a feeling of ” illness and heaviness.”
Her mother has exophthalmos, and had a large thyroid removed three years ago,
and which was not noticed until four years after the birth of the patient. A
paternal cousin is an epileptic. The points of interest in this case are the fact of
the mother suffering from glandular affection, and the fact of the menses becoming
more irregular as the epilepsy became more established. This might point to the
two having a common cause.

McKinnon, Johnson and Henninger, after describing alterations in the
clinoid processes observed in many epileptics, say that it is probable
that a moderate degree of hypopituitarism exists in all epileptics, and
that epileptic attacks are probably precipitated by sudden cessation of
practically all secretion from the posterior lobe.(22)

The pituitary gland has a stimulating effect upon the ovarian function,
and irregular menstruation is common in apituitarism.

Cases 1, 2, 3, 4 and 5 are of weak intellect, but fairly bright, and occupy them¬
selves usefully. Case 4 is, and 5 was, extremely irritable, and will fight and
quarrel with the slightest provocation. Case 6 might be considered of normal
mentality; she was smart at school, good at games, and said to be thoughful of
others, but occasionally irritable with children.

Cases 1, 2, 3 and 4 have been treated by us for epilepsy, and 6 was removed
from our care to be treated by Christian science. There are several cases of
epilepsy that have been reported as having been cured, or greatly benefited, by
anterior pituitary extract, the doses being from gr. viii to gr. xxx daily.

Cushing mentions 13 cases of apituitarism associated with epilepsy;
7 of them presented uncinate symptoms. All of these suffered from a
cerebral tumour. Two followed upon a fracture; the others were con¬
sidered to be primary glandular hypoplasia. The traumatic cases did
well on glandular treatment He treated some of these cases with

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whole-gland pituitary, giving as much as from 36 to 300 grains daily.
They improved mentally, lost weight, and the epileptic seizures were
either suspended or greatly diminished.(23) We have had no success
in treating these patients either with pituitary extract or with glands
that might act indirectly upon the pituitary. We have not given the
pituitary in the larger doses above recorded.

Case 7 is an occasional epileptic, dull and demented, upon whom no special
observations have been kept. His general conformation is much the same as
in the preceding patients except that he is taller. He was not admitted to a
mental hospital until he was seven years old, and was then too demented to give
any reliable history; probably the failure of his pituitary action and his epilepsy
are of late development, and due to arterial change in the neighbourhood of the
pituitary gland.

Case 8, an imbecile lad, set. 15, measuring 5 ft. in. and weighing 9 st. 4 lb.,
cannot read. He knows some letters but not others, knows figures, but cannot
do the simplest addition. He is quiet and good-natured, but easily led into
mischief by others more evil than himself. His general appearance is effeminate,
and his palate high and narrow. In three examinations his blood-sugar varied
from *12 per cent . to '14 per cent . Two hours after an injection of adrenalin ntvij
it dropped from *14 per cent . to *u per cent . He gave no sugar reaction in his
urine to five hours after the injection; he has no polyuria. In the blood-counts
his leucocytes averaged x 2,000 per c.mm. The polynuclears were 76 per cent., large
mononuclears 6 per cent., and small mononuclears 18 per cent .

Case 9, a Greek, at. 37, 5 ft. 6 k in. in height, weighed 16 st. 4 lb. He has vivid
hallucinations of hearing and delusions of persecution. For the most part he is
depressed and quiet, but subject to certain attacks of impulsiveness and violence.
His genital organs are much atrophied. In this respect the photograph is not
much good, as the penis is almost imbedded in fat, and cannot be recognised as
such. His skin is smooth and hair-growth abundant. He is a difficult case to
place from a glandular aspect, but might be considered a mixed one, in which an
apituitary and athyroid action play a part, with perhaps an over-suprarenal action,
accounting for the excess of hair-growth, and his blood-pressure being as high as
140 mm. Hg. In 1913 he greatly improved on the thyroid treatment, as advocated
by Drs. A. Davidson and H. H. Johnson, but lapsed back after a few months, and
since then it has not been possible to renew the treatment as any attempt to do so
greatly accelerates his pulse. Treatment with thyroid and pituitrin and pituitrin
alone has been without results.

Case 10 was a lad, set. 13 when admitted. Two years previously he had been
knocked down by a motor-car. He was unconscious for five days, and when he
regained consciousness he had a double internal strabismus, and complained that he
could see one object several times at once. Before the accident he had been a
normal boy of gentle disposition, obedient, and generally amenable, and well up to
the average at school. After recovery from the accident he became absolutely
untruthful and quite irresponsible, and it was found impossible to further educate
him. Twelve months after the injury he had fifteen epileptiform fits in one series.
After this his mental failure was more noticeable; he would wander away and
forget to return, became cruel to animals, committed male sexual practices and
his memory failed greatly. He was admitted in June, 1916, was then nicely spoken
and of attractive appearance, but absolutely devoid of moral sense ; would thieve
and lie in a most pleasant and natural manner. His memory was very deficient.
He had a remarkable chest development, with an expansion of 3 in. His hands
and feet were rather large, and the development of his organs of generation out
of all proportion to his age, otherwise he was about normal physically. About six
months after admission he became less alert and less talkative. His hair, which
had been fine and glossy, became coarse and thin, also his eyebrows became much
finer. His skin reflex, which had been red, continuing for several minutes, changed
to a distinct white, also lasting some minutes. He has, about every six months,
a series of four to five fits within a few hours, which leave him mentally dull and
confused for some days. Blood-counts made in February, 1917, gave an average

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leucocyte number of 7,637 per c.mm., of which the polynuclears were 61 per cent .,
small mononuclears 26 per cent., and large mononuclears 13 per cent. Another
differential count made a month later gave polynuclears 51 per cent., small lympho¬
cytes 27’5 per cent., large lymphocytes 12*5 per cent., eosinophiles 3 per cent.,
large hyaline 5 per cent., mast-cells 1 per cent. The blood-sugar ranged from
*07 per cent, to *n per cent., and a slight trace of sugar was found in the urine
one and a-half hours after subcutaneous injection of adrenalin nvvij. After
receiving thyroid gr. 1 twice daily for four months a great improvement was noticed
in his condition generally; he became brighter and the memory improved, though
his moral character became no better. The change in this lad followed a severe
head injury. It is probable that by this injury he received damage to the pituitary
body, the sexual over-development activity and perversion being explainable by an
irritative lesion of the anterior lobe, the effeminate ensemble to a want of secretion
of the posterior lobe, the symptoms of the athyroidism being secondary to those of
the pitituary. An X-ray picture of his skull was taken, and it was reported to
show no abnormality in the region of the sella turcica or elsewhere.

Case 11 is another apituitary patient, a woman, set. 32, and congenitally weak-
minded. She was at school for three years and can only read and write but little.
She is 5 ft. 1 in. high and weighs 15 st. 10 lb. Her chief characteristic is her
irritable temper. There is here some resemblance to an athyroid case, but her hair
is thicker and more glossy, her skin is smooth and moist, and in spite of her weight
she is an active worker and fairly quick in her movements. Her menstrual function is
normal and regular, commencing at eleven years of age. For four months she took
thyroid, gr. x daily, her weight dropping to 13 st. 10 lb. For the last twelve
months she has been having from 2i to 5 gr. of thyroid daily; while on this she is
brighter mentally and less quarrelsome and her weight keeps at about 14 st., and
rises to over 15 st. if the thyroid is discontinued. The thyroid acts in these cases
by stimulating the patient’s own pituitary gland action.

The next two cases show signs of over-suprarenal action. Case 12, an old lady,
set. 78 at the time of her death, was of very masculine appearance and possessed a
deep male voice. She had been an asylum patient for twenty years, and all that
time in a condition of chronic mania and constantly pugnacious. On post-mortem
examination her heart was found to be enlarged and fatty, with soft muscle and
atheroma of its vessels, the aorta being free from atheroma. The kidneys were
cystic and granular. The pancreas was large with a great deal of fat, and no
definite division between the gland and the fat. The ovaries were almost com¬
pletely atrophied. The thyroid weighed 2 dr. and each suprarenal 3 dr. It was
reported microscopically that the thymus showed no glandular elements. The
pancreas was extensively atrophied and the suprarenals degenerated. The thyroid
was inactive. Her masculine ways and appearance could be explained by over¬
action of the suprarenals, which had probably lately atrophied from age, and this
would account for the extreme atrophy of the ovaries and the activity of the
thyroid. The pancreas or suprarenals may have been originally at fault, their
action being antagonistic. The patients age was such that degeneration of all
glands might be expected, so the autopsy is not of the value it would have been at
an earlier age.

Case 13 is a demented epileptic of long standing. She shows fairly well-marked
male secondary sex characters. Her condition may have been brought about by
an over-suprarenal or a diminished ovarian action.

Case 14 is a small-headed imbecile, set. 31, with an abundant hair growth over
his body. He would lie about all day, could hardly be roused, would not converse,
had no interests, was quite indifferent to all things, and was of faulty habits. His
blood-pressure was under 100 mm. Hg., his blood-count about notmal, but the
small mononuclear cells were nearly as many as the polynuclear, the blood sugar was
*05 per cent., and there was no urinary reaction to 5 minims of adrenalin. The
dermographic reaction was white. We looked upon him as a case of over-supra¬
renal activity which had passed into one of under-action. He was given thyroid,
from gr. i to f daily, and an injection of adrenalin mv-x on alternate days.
This was continued intermittently for three months. The change was gradual but
great. He is now lively and bright, will converse freely, is a keen card-player,
employs himself usefully and has made two attempts to escape. The glandular
treatment has changed him from a vegetative to an active, if not intellectual.

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individual. He is probably now as of good, if not better, mentality than at any
period of his existence. After improvement was manifest some estimations
were made upon his blood-sugar, when it was found to vary from *05 to 'i6 per
cent . In three leucocyte counts made at this time the average was 12,000, of
which the polynuclears were 62 per cent., small mononuclears 31 per cent., and
large mononuclears 3 per cent. He now gave a slight urinary sugar reaction to
adrenalin v\x.

Case 15 is an unintelligent woman, set. 37, whose general appearance is like that
of a boy of eighteen years of age. She has no mammary development, no axillary
hair, and the hair on her head is thin and fine. The skin is darkly pigmented in the
axillse, around garter lines and on forearms. There is no dermographic reaction;
the thyroid and thymus are not detectable. She has never menstruated, and it is
reported that her ovaries and uterus sure infantile. This is a case of mixed glan¬
dular dystrophy, the ovaries and thyroid, as shown by want of physical and sexual
development, being primarily at fault, though there is a general want of gland
activity.

Case 16 was set. 58 at the time of her death. She was admitted to Callan Park
Mental Hospital in 1889, suffering from melancholia which had followed upon a
short attack of mania. Melancholia has been the predominant mental symptom
since, accompanied in later years by a progressing dementia. She is a typical case
of myxcedema, with rough dry skin, thickening of the subcutaneous tissue, thin
scanty hair, absence of eyebrows, the acute susceptibility to cold, slowness of
thought and action, and general apathy. She had been taking thyroid gland
for many years. It is noted that in 1894 and 1896 she was treated with this
drug but that no improvement followed. In 1903 she was again treated with
thyroid and with much benefit, becoming less depressed and more lively. From
this time to the time of her death she was almost continuously having gr. v-x
of thyroid daily. If this was discontinued for a short time she put on weight,
became so dull and uninterested that she would not even move of her own initiative,
became silent and would be faulty in habits. While taking the gland, although
depressed and morose, she would dress, take food, and look after and even occupy
herself. In July, 1917, she had four epileptiform convulsions in quick succession
and died two days afterwards. At the post-mortem examination there was much fat
everywhere, which made it difficult to define the limits of some of the glands, which
were themselves impregnated with fat. There was very little thyroid tissue, and
what there was was ill-formed and degenerate. The thymus tissue was also much
degenerated; the spleen was small, weighing 4 oz.; the kidneys lobulated, otherwise
healthy. The heart was fatty and the arteries very atheromatous. After micro¬
scopical examination it was reported that there was no evidence of active thymus
tissue, and that the ovaries, suprarenal and pituitary showed signs of much under¬
action.

Case 17 is set. 14 and Case 18 is set. 32. Both are simple and childish, incapable
of being educated, and both delight in playing with dolls. Case 17 is a Mongolian,
with the hands and ieet, dry skin and scanty hair of athyroidism. She has an
insane inheritance. She learned to walk at seven and to talk indistinctly at nine
years of age. She was very irritable and dribbled much. She menstruated at
13^ years, and at this time developed secondary sex characters and also sexual
inclinations, for which reason she was removed from her home. On from
gr. i to 2 of thyroid daily she made improvement, she grew and gained in weight,
the condition of the skin and hair improved, the dribbling habit ceased, and she
became quite talkative and talked more freely and clearly. It has been possible
to teach her to scrub, fold clothes, and generally help, which she does fairly
well and with much pleasure.

Case 18 was of rather different type, the skin and hair being normal; the hands
and feet were small, but not of the stubby formation of the former patient. She
was of low intelligence, could not talk distinctly, and could understand but
little of what was said to her. She suffered from attacks of tetany which were
associated with the menses. She died of cerebral abscess secondary to middle-ear
disease.

Case 19 was a case of gonod deficiency. The genital organs are infantile, the
breasts are large and pendulous, the fat distribution is of feminine character, and
there is a poor growth of face and body hair. The hands and feet are small and

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slender, the pelvis large and well formed, the voice high pitched and of peculiar
intonation. He was seventy years of age when his photograph was taken and was
admitted seven years previously. His intelligence is very limited and his con¬
versational powers are almost nil.

Cases 21 and 22 are both xt. 16, but have developed very differently.
Case 21 is 5 ft. in. in height and weighs 9 st. 8 lb., while Case 22 is 4 ft. 8| in.
and weighs 4 st. 2 lb. Case 21 made but little progress at school but is stated to
have been a good industrious girl in the house. Six months before admission she
became dull and listless, and talked nonsense to herself in a muttering tone, but
otherwise moped about taking no notice of anything. The menses, which had
hitherto been regular, became irregular and scanty, and she is said to have lost
weight. The symptoms followed upon a “ heavy cold.*' On admission she was
very dull, would repeat but would not answer questions, and was quite indifferent
to her surroundings. She passed urine apparently unconsciously, wetting her bed
during the night and her clothing during the day. She was well nourished, skin
smooth, soft and active, hair normal, hands and feet cold and damp. The pulse
was 88 per minute, and the blood-pressure was 120 when standing. The dermo-
graphic reflex was white, continuing for ten minutes. For six months she was
given suprarenal gland gr. v, and made rapid improvement. She became bright
and industrious and gained more than two stone in weight. Because of this gain
in weight and there being no symptoms of athyroidism she was given pituitrin and
varium, but continued to gain weight and weighed 12 st. 3 lb. when she left the
hospital eighteen months after admission. Her mental improvement has been
maintained, her mother reporting that the patient has never been so well as at
present. In this case there was probably some dysfunction of the suprarenals
following upon the “ heavy cold,” this being followed by diminished ovarian
action.

Case 22 is a very dissimilar one. She has been a hospital patient since she was six
years of age, and at that early age was given to violence. At the present she
appears about ten years of age, speech is very imperfect, no axillary hair, mammary
development is poor, and skin and hair are normal. The thyroid gland can be felt,
but the thymus cannot be detected. Chvostek reflex is present. The knee-jerks
are exaggerated and there is left ankle clonus. Dentition is good. Though of
childish and pleasing appearance she is a most evil minx. She will attack anyone
without reason or malice, will trip up or push down the old and feeble and will
come up smiling and spit in one’s face. She is filthy in habits, and throws fxces
about her room and has not menstruated. There is no special sign of glandular
deficiency. She is undeveloped both mentally and physically, the under develop¬
ment in this case being of cerebral origin.

Case 23 was xt. 18 on admission, 4 ft. 8 in. in height, and weighed 5 st. She
has but little intelligence, cannot read or write, and, although expressing a wish to
learn, on sending her to school it was found impossible to teach her. Physically
she is undersized and undergrown ; she has a peculiar growth of fine hair all over
the body, with but little axillary hair. There is a line of pigment on the abdomen
from the umbilicus to the pubis. The mammary development was poor on admission
but had increased six months later. Her thyroid gland cannot be felt. The
thymus is enlarged and can easily be percussed out. The bones are small and
slender, as are the hands and feet. The skin is smooth and soft, the sweat-glands
of axil lx being abnormally active. The pulse was 88 per minute. She has a
slight intermittent glycosuria, which was found on testing her urine previous to
an injection of adrenalin. Her blood-sugar at this time was *14 percent.*, two
hours after the injection it had fallen to ’05 per cent., the excretion of urinary sugar
being much increased. The hxmoglobin content is about 100 per cent.) the
leucocyte count averages 10,000 per c.mm., the polynuclear cells being 76 cent .;
small mononuclears 11 per cent., large mononuclears 7 per cent., eosinophiles 4 per
cent., masts and hyaline cells 1 per cent. each.

It is difficult to determine whether a thymus in this, and similar cases, is
primarily enlarged, or secondarily, as either compensatory or inhibitory to some
other gland. What results the enlarged thymus has upon growth and formation
probably depends upon the amount of over-action, the effects upon other members
of the endocrine system, and the time of life at which the enlargement occurs.
This case was treated for some months with suprarenal extract gr. v and gr. £

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thyroid daily. Except that she gained 8 lb. in weight and that her mammary
development has increased there has been no noticeable change.

Cases 24 and 25 are similar in their mental, but very different in their physical
make-up. Case 24, who is act. 14, is 5 ft. xoi in. in height and weighs 10 st. f
while the other case is a year older, 4 ft. 10 in. in height and weighing 6 st. 10 lb.
Both these boys had been to school, and although they had not done well, had done
fairly, and had commenced to earn their own living, Case 24 on a dairy farm and
Case 25 in a boot factory, and both were spoken well of by their employers. After
doing well at their work for a while they each took to wandering from home and
would remain away for days, seemingly doing nothing but walking the streets and
sleeping in empty houses or out-houses. Each would rob their parents before
starting from home, but had not been known to rob anyone else, except Case 25,
who, living in an orchard district, admits taking fruit for food. In each case the
thyroid could be felt, while Case 25 had an enlarged thymus but not Case 24. Case
24, whose bones were large and thick, hands and feet large, and genitals of abnor¬
mal development, might pass as one of over-pituitary action and was treated with
didymin to lessen this activity. The other lad has a generally diminished glandular
activity, with the exception of the thymus, which may be keeping the others in
check. Case 24, in three blood-counts, gave an average leucocyte count of 10,000
per c.mm. with polynuclears 52 per cent., small mononuclears 43 per cent . and large
mononuclears 5 per cent . He gave a slight urinary sugar reaction two hours after
an injection of adrenalin n\x. The blood-sugar on two examinations was 05 per
cent, while on a third it was *14 per cent. This was previous to the adrenalin
injection, after which it fell to *11 per cent . No blood observations were made on
Case 25.

The two boys soon returned to their normal mentality and left the hospital after
six months’ residence. Case 24 has been out more than twelve months and is reported
to be doing well. Case 25 was returned after being away a month, as he was
inclined to wander and did not settle to work. About a month later his parents
insisted on removing him to a Salvation Army home, and to us he has been lost
sight of, but he should be doing as well as his companion.

Case 26 is aet. 18, weighs 7 st. 12 lb., and measures 4 ft. 9} in. His hair and
skin are normal, and his bones short and thick. He has a fair amount of sense, is
capable of useful occupation, but has no initiative. He has no idea of the value
of money, is easily led into mischief, and readily becomes a tool of others, which
was the reason of his admission. This is a case approaching achondroplasia. He
contrasts with the cases 27,28 and 29, three Mongolian imbeciles, with the spade-like
hands and feet, the rough dry skin, thick lips, and undershot jaws, scanty dry hair
on head and deficiency of body hair. Case 29 gives a distinct white skin reaction
lasting ten minutes, and passes about 3,000 c.c. of urine in twenty-four hours. His
leucocytes average 6,500 per c.mm., the polynuclears being 58 per cent., the large
mononuclears 14 per cent., and the small mononuclears 28 percent. In three exam¬
inations his blood-sugar varied from *05 per cent, to * 15 per cent. After an injection
of nt x of adrenalin his leucocytes rose from 5,062 to 24,750 per c.mm.; there
was a slight rise in the blood-sugar but none excreted in the urine.

Case 28 was 5 ft. 10 in. in height, and died of colitis at the a^e of 45. At
the post-mortem examination, made twelve hours after death, his brain was found to
weigh 39 ounces; his heart was normal, except that the aorta would only admit
one finger. There was a considerable amount of thymus tissue scattered about
the mediastinum. The thyroid was small, the suprarenals were large, but were
apparently mostly fatty tissue. •

Case 64 is one of a peculiar oedema, and follows fairly exactly the description of
Milray’s disease, but there is no hereditary history. She was first admitted to a
mental hospital in December of 1911. Her mental condition had been diagnosed
as recent mania, and moral insanity. She had been sent to a reformatory at quite an
early age and at eighteen she went into service, and shortly after eighteen had a baby.
In January, 1914, she was treated for retroflexion of the uterus, pyelitis and cystitis.
She was subsequently treated for a double salpingitis and later a left salpingo-
odphorectomy was performed. Later in the same year she suffered from gonorrhoea.
She came under our care in March, 19x6, and was then in good physicial health. In
April of that year she complained of pain in the right hip-joint, after which for
three months she persistently complained of pain in one of the joints of the right leg.

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CASES WITH ENDOCRINE CONSIDERATIONS, [Jan.,

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Towards the end of July the right ankle-joint was swollen and at this time it was
noticed that she had a few pus-cells in her urine and some diplococci. In
November, 1916, the right leg from the hip to the ankle was swollen and cedematous.
The blood was repeatedly examined for filaria, but with negative results. In
January of 1917 the leg was very swollen and she complained of severe headache.
A lumbar puncture was performed and 17 c.c. of fluid was removed under a plus
pressure. Three days after the puncture the leg was almost normal, but had
returned to its original degree of oedema within the next week. In October of
1917 the left leg below the knee became cedematous. The next month the left leg
and thigh were cedematous, as was the right. A silk-worm-gut drain was put into
the inner surface of both thighs, but no benefit followed this, although they drained
freely for a time. A lumbar puncture had been repeated once or twice but never
with the same result as the first time. In February of 1918 several incisions were
made into the legs, which drained freely, but they did not diminish in size. About
this time numerous hard round nodules developed ; they were very tender to
touch. Two were removed and examined under the microscope but no lepra bacilli
were found. In this month the right arm became swollen, and there was a tender¬
ness along the course of the nerves. In March she complained of a great deal of
temporal headache. Twenty c.c. of ccrebro-spinal fluid were removed under
increased pressure, after which the headache improved, and the legs became
smaller, though nothing like normal. In April of the same year she complained
of much abdominal pain and often vomited. The headaches again became severe.
A lumbar puncture was repeated with relief to the headache, but it was not
followed by any lessening of the swelling of the legs or arm. Injections of
adrenalin mx and calcium iodide gr. xv were given into the scapular region
every second day for a fortnight. The swelling in the legs became much smaller,
the decrease being most marked the day after the injection. She then objected to
the injections and they were discontinued. Between May and September the
injections were repeated several times for about ten days or a fortnight at a time,
each time with much diminished swelling of the legs, more especially the left; the
thighs at one time became normal. When the oedema was diminished the patient
complained of very much more pain in the legs. In October of 1918 six injec¬
tions of pituitary, 1 c.c., were given on alternate days and after the second dose
there was some improvement, but this was not lasting. In December of the
same year the right arm began to swell—first the hand and forearm, then above
the elbow. Another series of injections of adrenalin and calcium were given, the
two drugs this time being given separately. The patient became resistive and the
treatment was discontinued. After these six injections there was marked improve¬
ment. In January of 1919 the left arm also commenced to swell and the right
became bigger still. During the next month both arms and both legs were
extremely swollen, and she was unable to move any one of the four limbs.
The patient now implored to have the treatment resumed, and this was only con¬
sented to on the condition that she would be treated as long as was thought
necessary, and that she would take and do all things as told. She was given 1 c.c.
of adrenalin, and this was repeated every second day. By February 18th the left
arm and hand were normal, the right hand nearly so, the swelling of the left leg had
disappeared except of the foot and ankle, the right leg was smaller, and the
cedema softer, and would now pit on pressure. Always before, when patient’s
legs were going down, she had vomiting attacks and severe abdominal pain, but
this time these were not so severe, but she complained of a great deal of pain in the
limbs as the oedema diminished. In March of the same year both hands and arms
were normal, and she had free use of them. The left leg was also normal. From
July the adrenalin injections were continued for ten weeks. They then caused
giddiness, breathlessness, and much pallor of the face, so they were reduced in
Frequency and amount, and afterwards discontinued. Suprarenal tabloids gr. xv
and gr. i of thyroid daily were substituted. The improvement has been slow but
continuous, and there has been no return of the oedema of the upper extremities.
That of the lower limbs has persisted, though it has been much more variable,
the degree of swelling altering from day to day. The patient’s mental condition
has undergone a great change for the better. She is now affable and cheerful,
whereas formerly she was most morose and taciturn.

The differential diagnosis of this case is by no means easy. The patient at times

Gougle

Original from

UNIVERSITY OF MINNESOTA

BY GUY P. U. PRIOR, M.R.C.S.

1920.]

during her illness was extremely resistive both to treatment and examination, for
which reason observations upon the chemistry of her blood and urine have not been
made. In the earlier stages of her illness she was thought to be suffering from
gonorrhoeal rheumatism, and finding diplococci in her urine supported this supposi¬
tion, which could not be maintained when the leg became generally cedematous.
The diagnosis then rested between an oedema of venous or lymphatic origin. No
filaria could be found in the blood nor could any cause for a venous block be found.
It was self-evident that the oedema was not of cardiac, portal or kidney origin,
though there was often a trace of albumen in the urine. An angio-neurotic oedema
was considered, but as a rule the oedema in these cases comes and goes quickly,
attacking first one and then another site. Later when two and then a third limb
was attacked, the case exactly resembled one of Milray’s disease, which is described
as an oedema which first attacks one limb, then another, until all four limbs are
affected; it persists until the patient either dies from exhaustion or from some
intercurrent disease. According to descriptions, the one essential of Milray’s
disease is that it is hereditary, but no hereditary history could be obtained in this
case either from the patient or her friends, her parents having died when she was
quite young, the family separated and were brought up by the State, and so no
great reliance can be placed upon the family history. No pathology has been given
to Milray’s disease.

(Edemas, sometimes persisting, sometimes very transitory and without any
apparent cause, or with such insufficient cause as long standing, are not uncommon
in the insane, though the pathogenesis of these have not, as far as we are aware,
received much attention as yet.

We look upon this case as likely to be due to some lesion of the sympathetic
nervous system. We gave her adrenalin under this idea, and the calcium because of
its action upon the blood-vessels. Her blood-pressure previous to the adrenalin
injections was within the normal range, nor was there any increase after the injec¬
tions, even when the larger doses were being given. A sign of insufficiency of her
own adrenalin system was the fact that only upon about two occasions was there
sugar in the urine, even after repeated 1 c.c. doses of adrenalin. It is advised that
adrenalin be not given repeatedly even in small doses, but in this case it seemed to
be doing nothing but good, and the case appeared so hopeless otherwise. Her
menses had been in abeyance for some twelve months, but reappeared at irregular
intervals while receiving the calcium iodide and adrenal injections and continued
fairly regularly while receiving larger doses of adrenalin.

My thanks are due to Mr. E. C. Wood for reading and correcting the
manuscript, for aid and advice in its formation, and for typing the final
copies, and also to Mr. A. Lyon, the Chief Attendant, for much help in
the laboratory and in the care of the guinea-pigs and tadpoles.

[It is regretted that owing to the prohibitive cost of reproduction
numerous other interesting photographs which illustrated this article
could not be published.— Eds.]

References.

(1) Endocrinology , vol. i, p. 133.

(2) D. N. Paton.—Ref. Regulators of Metabolism, p. 118.

(3) Endocrinology , vol. i, p. 344.

(4) Harmsworth.— Natural History, pt. 12, p. 605.

(5) McCarrison.— The Thyroid Gland, p. 144.

(61 ‘Thyroid Insufficiency,” Practitioner, January, 1915.

(7) Practitioner, February, 1915, p. 181.

(8) Endocrinology, vol. ii, No. 3, p. 336.

(9) “ Epilepsy and the Ductless Glands,” Journ. Ment. Sci., June,
1918, p. 58.

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tuberculosis sectioned tioned active active

TREATMENT OF GENERAL PARALYSIS,

[Jan.,

(10) Ref. Med. Jourtt. of Australia, June ist, 1918.

(11) Orten.— Amer. Jourtt. of Insanity , vol. lxxi, p. 579.

(12) Bandler.— Med. Gyncecology, p. 157.

(13I Osier and Macrae.— Modem Medicine, vol. iv, p. 781.

(14) Falta.— The Ductless Glandular Diseases, p. 336.

(15) Osier and Macrae.— Modern Medicine, vol. iv, p. 787.

(16) Harrower.— Practical Hormone Therapy, p. 2.

(17) Tobias.—Apocrypha, chap, vi, verses 2 to 17.

(18) A. Davidson and H. H. Johnston.—“Use of Thyroid Extract
in the Treatment of Mental Disease,” Aust. Med. Cong. Trans., 1911,
vol. ii, p. 817.

(19) Falta.— Ductless Glandular Diseases, p. 305.

(20) Cushing.— The Pituitary Body and its Disorders, p. 268.

(21) Falta.— Ductless Glandular Diseases, pp. 290 and 291.

(22) Ref. Practical Medicine Series, vol. ix, 1914.

(23) Cushing.— The Pituitary Body and its Disorders, p. 272.

Regarding the Treatment of General Paralysis. By G. H.
Monrad-Krohn, M.D.Christiania, M.R.C.P.(Lond.), Physician
to the Neurological Section of Rikshospitalet, Christiania; Lecturer
in Neurology to the Royal Frederick University, Christiania.

When Noguchi found spirochaetes in the brain of general paralytics
some years ago it seemed as if we were entering into a new era, not
only in the pathological conception of the so-called “parasyphilitic” or
“ metasyphilitic ” affections, but also in their treatment. In this latter
respect most of us have hitherto been somewhat disappointed, and it
may therefore be advisable to take up the rationale of the treatment for
revision.

The reason why the usual antisyphilitic remedies are of little or no
effect in these affections may be found in one or more—perhaps all—
of the following possibilities:

(1) Either the antisyphilitic remedies or the antibodies—the forma¬
tion of which they give rise to—do not get access to the spirochaetes on
account of their anatomical localisation;

(2) Or the spirochaetes may have acquired an immunity to the anti¬
syphilitic remedies (*);

(3) Or the initial spirochaete affection of the cortex may have already
started a vicious circle, which per se will lead 10 destruction irrespective
of the spirochaetes.

(4) Finally the possibility must also be kept in mind that meta¬
syphilitic lesions may be due to a mixed infection of spirochaetes and
some other microbe or microbes (e.g., Porter Phillips’s diplococcus or

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BY G. H. MONRAD-KROHN, M.D.

1920.]

Ford Robertson’s diphtheroid); the fact that syphilis only in com¬
paratively few cases is followed by “metasyphilitic” affections shows
us that these must be due to syphilis + something else, and this some¬
thing else may quite well be a microbe. The possibility of this microbe
“ carrying on ” alone after being “ introduced ” by the spirochsete must
also be faced.

With the first-mentioned alternative in view one tried to inject
salvarsan solution directly into the cerebrospinal fluid, but as this
frequently led to unpleasant spinal complications, Marinesco proposed
to inject salvarsanised serum into the cerebrospinal fluid. Swift and
Ellis followed Marinesco’s lead, and lumbar puncture, followed by
injection of salvarsanised serum, rapidly gained ground as the most
rational way of treating tabes. As regards general paralysis, it was
felt that the intraspinal injections could be of no avail and different
forms of intracranial injection methods were introduced. The most
practical of these, I still venture to believe, is the one which I developed
and described in Norsk Magazin for Lcegevidenskaben , Christiania,
No. 5, 1914, and in a letter to the Lancet in the spring of T914 (May¬
or June as far as I remember), also in the Journal of Mental Science,
April, 1915. Schroeder and Helweg have also used this method with
some modifications (cf their interesting article in this Journal, January,
* 9*9 (*))•

I think it is too early to draw any definite conclusion from the
experience yet gained. My own experience comprises but sixteen
cases, and the only conclusion I feel justified in putting forth is that in
advanced cases of general paralysis of the insane the proposed treat¬
ment has no appreciable effect. If in early cases it has some effect
I do not yet feel justified to express a decided opinion. Several of my
cases are “promising,” but then the early spontaneous remissions
complicate the question post aut propter. On the whole one cannot
yet expect conclusive experience regarding the result of the treatment.
At least five years’ continued observations of a large number (fifty or
more) of early cases will be necessary as a basis for a more definite
opinion.

My object in writing these lines is therefore not to give the result
of my scanty experience, but to draw the attention to the above-
mentioned possibilities, of which it appears to me that (2), (3) and (4)
have been neglected. If an inaccessible situation of the spirochsetes
as regards the antisyphilitic remedies were the only reason of the failure
of the ordinary antisyphilitic treatment, it strikes me that we should
already now have obtained more striking results from the salvarsanised
serum treatment ; even in advanced cases one would then expect an
arrest of the disease, which I have satisfied myself one does not get.
For these advanced cases I am inclined to believe in some vicious

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TREATMENT OF GENERAL PARALYSIS. [Jan.,

circle having been established leading per se to destruction (3). The
question must therefore be studied in early cases, and here the possi¬
bilities (2) and (4) must also be taken into account.

An acquired immunity on the part of the spirocbsetes might possibly
be broken down by a simultaneous attack through different “haptophore
groups ”—at least experiments on trypanozomes lead us to believe so.
Consequently simultaneous administration of mercury should be com¬
bined with the intracranial salvarsanised serum method. Hexamethylen-
te tram in (urotropin) should also be given from this point of view,
and this latter modification would also help to counteract any mixed
infection (4). A simultaneous treatment with antimony might perhaps
also be tried. That the remedies advanced by McDonagh may help us
here future experience only can decide. One must keep an open,
unbiased mind, and if a number of remedies can be found which
all attack the spirochsete through the different “ haptophore groups,”
this will signify a great advance in our attempts at combating the
“ metasyphilitic ” affections.

Finally a few words about salvarsanised serum. What is salvarsanised
serum ? What is its active principle ? Some authors claim salvarsan
itself to be the active principle; others hold that the antibodies formed
in consequence of the salvarsan injection (the death of spirochaetes and
liberation of endotoxins) form the active principle. According to the
different opinions some physicians take the blood immediately (quarter
to half an hour) after the salvarsan injection; others wait twelve hours
or more. As long as this question has not been decided I think, it
safest to take the blood half an hour after the salvarsan injection. In
this way the serum will contain the salvarsan from the immediately
preceding intravenous salvarsan injection, and with repeated injections
also the antibodies formed in consequence of the previous salvarsan
injections.

We may be—and probably are—on the right way to solve the
question of treatment of general paralysis of the insane. And yet we
may fail if we do not face all the possibilities that obtain.

(') If the spirochaete has a life-cycle (as McDonagh will have it), it would not
be surprising to find certain phases of the life-cycle immune to the usual anti-
syphilitic remedies.—(*) With regard to the modifications they propose, I shall
just mention that after injection of the full dose of 0 9 neosalvarsan arsenic can
be found in the blood, and anyway, it is on account of such concentration in the
blood after intravenous injections that it acts on syphilitic lesions in other organs.
Why should a stronger concentration be needed in the brain f

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1920.]

REVIEWS.

Part II.—Reviews.

My Life and Friends: James Sully, LL.D. London : Fisher Unwin,
1918. 8vo. Pp. 356. Price 12s. 6 d. net.

First of all, one must commend this book as a most agreeable
pastime, full of general interest, and also, from our standpoint, instruc¬
tive. Your reviewer has special interest in contributing something in
reference to the book, for the author and he not only belonged to the
same social club, but were both fellow Sunday tramps with Leslie
Stephen, and in many respects there was a strange parallel in their
youthful surroundings. There was also a similarity in age.

James Sully was the son of a Bridgewater tradesman, who was an
ardent Gladstonian Radical and also a Dissenter. These qualifications
to a certain extent interfered with his general social life, so that the
society in which the son of a Radical tradesman and a Dissenter mixed
was essentially unlike the society which the majority of literary men
have passed through.

To begin with, his schooling was of the most mixed kind. He was
sent to various “ dames’ ” schools, and was never at any really public
school, the result being that his education was not so much by book as
by observation and family relationships. He was particularly happy in
bis family, parents and sisters all being intelligent and earnest. The
fact that he did not go to a public school and then to a classical
university turned his thoughts more on to science and to general
history and literature than otherwise would have been the case. Music
was one of the great resources of the family, and Sully developed great
taste and ability along musical lines. Later, besides taking an interest
in natural science, he also took practical interest in drawing.

He began, as I have said, in the rather narrow local schools. Later
he was under tutors and went in for the University of London examina¬
tions. Still later he went to German universities, where he formed
many life-long friendships.

His father was particularly anxious that he should become a Methodist
minister, and for many years, although he had no special religious “call”
or inclination, yet he felt that it was a useful and interesting occupation,
and in a calm, unattached way, to be a duty to pursue theological
studies. These did not seem to upset his general faith and belief until
he went to Germany, when distinctly his views were broadened or, we
may say, widened, and slowly he came to the conclusion that at all
events it was not his part to become a recognised minister. In many
ways, therefore, he and Leslie Stephen passed through parallel mental
states. Leslie Stephen became a clergyman, though he practically never
officiated as such; and Sully was qualified as a minister, but did not
take up the duties.

Slowly Sully’s ideas passed from faith to agnosticism, and with men
like Huxley and Leslie Stephen he was a follower of higher ethics and
morality. Religious dogmata did not appeal to him.

Fortunately for him, his father was, at all events for many years,

LXVI.

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wealthy and able to contribute to his education, so that he travelled far
and wide and spent much time in continental schools. But he was
anxious to get some work, and he began as a journalist, and through
the influence of men like Leslie Stephen and Morley he secured
journalistic work, and he contributed an enormous number of articles
on a very large number of subjects. He did a great deal of reviewing,
and one of his first independent essays was on “ Pessimism.” This led
to a certain amount of misunderstanding, because he himself was
anything but a pessimist. But the title seemed enough to rather
condemn him in the eyes of certain people.

Later on he devoted much more time to the study of ethics and
so-called psychology. He studied Bain, Herbert Spencer, George
Lewes and W. James. He took independent views in relationship to
all their writings, and himself wrote more than one book on psychology,
the original idea being that the book should be a standard for examina¬
tional purposes. Later, this developed into the larger work, The
Human Mind, in two volumes. There is independence of thought and
careful observation in all these works. Whatever Sully was, he was an
observer and a recorder. He was not content simply to saturate himself
with the ideas of ancient philosophers, or to swallow whole the philosophy
of the modern French or German writers. The result has been quite an
independent line of thought.

Besides these, he wrote other books, some having given him a peculiar
pleasure, and certainly, to my mind, displaying the man’s character
much better than even his psychological writings. For instance, the
book entitled Child Studies is simply a further evidence of the kindly
child-loving nature of James Sully. He wrote also an interesting book
from what might be called the emotional side, entitled Human Laughter ;

But it is quite beyond one’s power to enumerate the thousand-and-one
articles, reviews and books that he wrote or contributed to. He was a
most voracious reader, and owing to his literary work and his writing
he suffered from a nervous breakdown and had to have a rather
prolonged rest abroad. At the same time he was suffering from his.
eyesight, so that it became absolutely necessary for him to refrain from
real brain work. He recovered completely, and it was only later that
he once more went to live abroad.

He established himself at Hampstead, and at the time he was
there, there were a good number of artistic, literary and scientific
residents, who formed little social clubs, and it is quite evident that
in those days Sully was a very social person and quite capable of
enjoying good society and good dinners !

In this Life he refers to his neighbours, especially those about
Hampstead. He also refers to their social gatherings.

He had a wonderful gift of friendship, and throughout the whole
of the book it is noteworthy that there is scarcely an unkind remark
about anyone. In fact, one would say there may be slightly critical
remarks, but none that are really harsh. Evidently the temperaments
of men like Bain and Herbert Spencer were not congenial to him.
Men who were physically unfit, who suffered from indigestion, or were
incapable of taking vigorous exercise, were not likely to be long friends
of Sully.

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I do not think I ever came across any book in which what might be
called the thumb sketches of character are so well given. And when
one thinks of the numbers of friends that he had made and kept, it is
certainly astonishing. A considerable number of his friends, of course,
were literary, but there were, besides, the scientific friends and many
musical ones. He was a friend of Huxley, and Darwin; and Romanes,
who died so early, was a man in whom he was distinctly interested and
with whom he was sympathetic, though he failed to follow Romanes in
his religious thoughts. Besides those mentioned, Leslie Stephen and
George Meredith probably had the greatest influence upon his life and
conduct. He worshipped Meredith from the literary and social points
of view, and he admired Leslie Stephen, both from the philosophical
standpoint and also for his muscularity. Sully was an athletic man,
although not a powerfully built man. Yet he was good at many sports;
he was an excellent swimmer, he did a considerable amount of climbing,
both in England and abroad. But walking probably was the thing that
interested him most, and he and I were both members of Leslie Stephen’s
Sunday tramps. His descriptions of the meetings of these tramps under
the guidance of Leslie Stephen give a very clear idea of the kind of
society that Sully sought and the society that appreciated him.

As I have said, his religious views passed from a more or less definite
faith into agnosticism. Politically he was a Radical, and I suppose may
be called a Pacifist. He was one of the very exceptional men in England
at the time of the Boer War with pro-Boer tendencies, and ran a certain
amount of risk of being misunderstood. He tried to get others of his
friends to join him in some more active demonstrations against the
Government, but fortunately in this he was over-persuaded. The very
strongest views of liberty of thought, liberty of mind, and of absolute
rectitude ruled his life from beginning to end.

As one goes on with the book one is very much struck with the
tender-heartedness of James Sully. One by one his most intimate
friends, like Leslie Stephen and George Meredith, Romanes, Spencer,
Bain and others died, leaving him, if not alone, yet deprived of many
of his old friends; and as he points out, getting on in years it is much
easier to lose than to gain friends.

In conclusion, one can only say that the book is eminently worth
reading, and gives, one may say, an epitome of the social life of the
educated circles in and near London during the last fifty years, and
leaves one in the hope that Sully’s work is not yet over. He is honorary
member of the Neurological Section of the Royal Society of Medicine.

G. H. S.

Syphilis and the Nervous System. By Dr. Max Nonne. Translated
by Charles R. Ball, B.A., M.D. London and Philadelphia:
J. & B. Lippincoit & Co., 1916. Second American edition,
revised. 8vo. Pp. 450. Illustrated. Price $18 net.

This volume, the second American edition of Syphilis and the
Nervous System, is a translation of the third German edition published
by Dr. Max Nonne in 1915.

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In the arrangement and in the material content of the majority of the
chapters the book differs little from the previous edition; the author
has remained true to his profession of writing from the practice for the
practice, and, as he emphasises the importance of the symptomatology
and of clinical observation in dealing with the syphilitic diseases of the
nervous system, the book, which is rich in clinical detail, remains much
as before.

The chapters on dementia paralytica and tabes dorsalis have, how¬
ever, undergone considerable modification in the light of the discovery
of the Spirochata pallida by Noguchi, in the brain of the paretic and
in the spinal cord of the tabetic. The demonstration of the organism
of syphilis, coming with the evidences furnished by the cytological and
chemical examination of the cerebro-spinal fluid in cases of general
paralysis and tabes dorsalis, has finally settled the long-drawn-out dis¬
cussion as to the specific origin of these conditions. Nonne agrees
with the English neurologists, Mott, Head and others, that “the clinical
manifestations of parasyphilis are an expression of the reaction and
necrosis of hypersensitised areas of the nervous system, evoked by the
reappearance of the Spirochata pallida ”; he differs, however, from
Mott’s assumption that the inflammatory condition of the neuroglia and
blood-vessels is a secondary effect of the primary nervous degenerations,
which was his opinion before the discovery of the spirochaeta in the
brain. But that is not his opinion now.

He considers that the case for a specialised strain of organism with
a specific affinity for the nervous system is not yet proven, and he
differs, on the one hand, from the view of Nacke, that the neuropathic
disposition is an important factor in the genesis of these conditions, and,
on the other, from Kraepelin in his opinion as to the predisposing
influence of alcohol.

It is of interest to note that Dr. Nonne is inclined to deny the
impossibility of recovery in paresis. He cites the occurrence of cases
“whose enrolment under the diagnosis of paresis no one would have
doubted had the termination been the customary unfavourable one.
The fact alone that the termination was favourable should not, in my
opinion, change the diagnosis.” The question, however, is a difficult
one to solve on account of the lengthy periods over which remissions
of the disease have been known to extend, and, in the cases quoted by
the author, in support of the view of recoverability, none had been under
observation for more than six years. The author, however, does not
state that the patient had not suffered from any brain deficit.

The chapter on the behaviour of the Wassermann reaction in the
blood and spinal fluid, the occurrence of pleocytosis and the increase
of globulin in the spinal fluid is most instructive. In it is given, in
schematic form, an estimation of the value to be placed on the positive
or negative findings in either case, also an authoritative statement as to
what influence the results of examination of the blood and spinal fluid
should be allowed to have in determining the prognosis and the further
treatment of the particular patient concerned. In this connection,
Dr. Nonne states that when the four reactions are all negative one may
conclude that the syphilis of the patient has really ceased to exist; he
adds that he has seen a large number of such cases. “ The persistence

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of one or more of the four reactions demands a continuance of the
treatment in cerebrospinal lues. In tabes and paresis the persistence
of the three reactions in the spinal fluid is no indication for the con¬
tinuance of the treatment, for, in these diseases, the three reactions,
save in rare cases, are uninfluenced by any therapy with which we are
at present familiar.”

A special chapter has been added on the question of salvarsan
therapy. Here the whole question of the treatment of the syphilitic
nervous disease is dealt with, full details of the methods to be adopted
in the various forms of administration are given, from that for the
administration of the now somewhat antiquated original “ 606,” to that
to be followed in the intraspinous injection of salvarsanised or mercu¬
rialised serum. As regards the cases treated by the author with these
latter methods, he was unable to notice any difference in their course
than in cases treated by the usual methods.

Out of his own experience, Dr. Nonne advocates the combination of
mercurial inunction with the adminstration of the arsenical compounds.

In his conclusions as to the value of the arsenical compounds the
author is terse and to the point. He states that in cerebrospinal
syphilis in individual cases, a quicker and more far-reaching result may
be obtained with salvarsan than with mercury and iodide. There are
also cases in which salvarsan has been effective after the older remedies
have failed or have had an insufficient effect. The cases in which
salvarsan has had an entirely favourable effect are, however, in the
minority. In the majority the superiority of salvarsan over mercury
and iodide is not apparent. In tabes and paresis the newer remedy is
of no more avail than the older ones.

Dr. Nonne, though he admits the evidence pointing to the accerba-
tion of certain cases following treatment by the arsenical compounds,
deprecates the idea of any serious danger, and would not permit such
considerations to interfere with the laying down of the course of treat¬
ment. He advises commencing with the smaller doses, but considers
that the intensive treatment has definite advantages in certain cases.

Detailed accounts are given of the tuberculin, the sodium nucleinate,
and the vaccine method of treatment of nervous syphilis, though here the
author has little to say in regard to his own experience of these methoda

He concludes his chapter partly with a warning against the “ Furor
Therapeuticus,” which the laboratory reports have tended to instigate.
He reminds his readers that the older and more experienced physicians
used to say that a case was refractory to treatment if a six weeks’ course
of mercurial administration did not produce recovery or marked improve¬
ment. Many cases of nervous syphilis, and especially tabes and paresis,
do not very well bear energetic treatment, and he much doubts the
wisdom of the dictum that the treatment should be continued until the
spinal fluid is normal.

In conclusion it may be remarked that, quite apart from the value of
the book as a record of a large and extensive experience, the essentially
practical manner in which the author has handled his material con¬
stitutes a strong claim for its usefulness to every practitioner who may
have to deal with problems of the diagnosis and treatment of syphilitic
diseases of the nervous system.

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Morbid Fears and Compulsions: Their Psychology and Psycho-analytic

Treatment. By H. VV. Frink, M.D. London : Heinemann, 1918.

8vo. Pp. 568.

This book is prefaced by an introduction from the pen of Prof.
J. G. Putnam, of Harvard, who testifies to the abundant knowledge
and conscientiousness of the author, a New York physician already
known as closely associated with the American branch of the psycho¬
analytic movement. He is of the strictly Freudian school, making
little reference either to Adler or to Jung, but he is a follower in no
slavish sense, presenting the old doctrines in a fresh and personal way,
and while not seeking to explain them away where to some they seem
repellant, he yet puts them forward in a simple, straightforward, reason¬
able way likely to disarm many opponents.

There are, Dr. Frink remarks, three classes of readers to whom a
book on psycho-analysis may appeal: those who are entirely ignorant
of the subject; those who know something and wish to know more with
the probable intention of putting their knowledge into practice; and
those who know so much that they are only interested in questions of
technique and elaborate cases. It is To tfee second class of reader he
appeals, and it is for physicians who desire to take up psycho-analysis
in practice that his book will be chiefly valuable.

The book covers wider ground than its title may suggest—indeed, the
whole field of medical psycho-analysis. If, in accordance with Freudian
doctrine, we are concerned with sex interests in the largest sense (to avoid
the danger of unduly narrowing this sense of the word “sex” Flink pre¬
fers to call them “ holophilic ” interests), fear is to be regarded as' either
the repressed wish or libido itself converted into another form, or,- we
may better say, the protective reaction against the libido. It is the
embodiment of the prayer, “ Lead us not into temptation ”—the classic,
prayer of him who is afraid of his own desires. The task before the
author is thus that of expounding all the chief primary Freudian
conceptions with special reference to the neuroses. Sometimes he
does this in Freud’s own words. More often he sets forth the doctrine
in his own way, showing a clear realisation of its significance and
illustrating it at every point by observations drawn from his own rich
experience. In further illustration he brings forward a detailed case
(over 100 pages) of compulsion neurosis and a shorter history of anxiety
hysteria. Throughout, the author shows his practical common-sense
attitude by confining himself to the essential features of a case, and
avoiding the fine-spun elaborations, of interpretation which sometimes
fascinate the psycho-analyst and arouse the wrath of the sceptic.
Perhaps the most original feature of the book is an attempt to bring
the Freudian conception into harmony with the behaviouristic psy¬
chology, but the author modestly disclaims his competence to do more
than suggest this briefly.

Dr. Frink’s wide and thoughtful attitude is well exemplified by the
closing pages, in which he discusses some of the deeper implications
of psycho-analytic therapeutics. It is- not, he remarks, mere “ knowing ”
or “understanding” which cures the patient; it is the living over again
of what has subsided from consciousness which has the therapeutic

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effect. Just what this consists in, or why it should have this beneficial
effect, remains, it seems to the author, decidedly obscure; we can
hardly even guess. It is clear, however, that psycho-analysis is a
re-education, and in the fullest sense, not, as so often education is,
a process of repression—a Procrustes’ bed to which the child is forcibly
fitted—but a real leading out of the energies along the lines that give
them fullest and most advantageous expression. In the re-education
of psycho-analysis this false education has often to be undone; the
resistances dissolved by the analysis are in part those instilled by a
supposed moral training. Thus, in a sense, psycho-analysis tends to
destroy morality, but it is a false morality which is thus destroyed, and
“ the result of overcoming certain moral inhibitions may really be the
attainment of a higher degree of morality than was possible while they
were in force.” The conscience is re-formed into a shape that furthers
the welfare of the individual and increases his adaptation to life. That
the process is not easy and that much circumspection is needed to
avoid danger the author readily admits.

It may be noted that the death of Prof. Putnam, who wrote the
introduction to Dr. Frink’s book, had already occurred before the
publication of this English edition. His final appearance here was
characteristic of the man, for he had always been a pioneer, and among
the older generation he was the most distinguished who came forward
in America at an early stage as an avowed supporter of Freud, though
his support was given in a judicial and discriminating spirit, as is clear
even from this introduction. He died leaving behind him, Prof. Lowell
has said, the reputation, not only of a physician of the highest attain¬
ments, but of “ philosopher and saint.”

Havelock Ellis.

How to Enlighten our Children. By Mary Scharlieb, M.D., M.S.

London : Williams & Norgate.

Dr. Scharlieb maintains that it is the duty of parents to prepare their
children for the part they have to play in life, but, through ignorance or
diffidence, this is too often neglected. The young man or woman is
left uninformed of sexual hygiene, often with injurious results.

This book, which is written for parents, presents the necessary
information and tells how and when the knowledge should be
imparted.

The changes in the structure and functions of the body and the
mental and moral outlook in puberty and adolescence are described m
simple language. It is pointed out how necessary it is, at these
transition periods, for a mother to explain what these changes mean and
how essential it is for her to help her daughter to look after the general
health by proper feeding, recreation, clothing, etc.

In the chapter on reproduction valuable advice is given on imparting
the information to the child. This is led up to by a description of the
reproduction processes in plants and animals.

Dr. Scharlieb considers that the parents should be frank and open in
communicating these facts, and she believes that, if the child is asked to

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treat them as confidential, the desire to guard the secret will overcome
the natural inclination to speak of it to others.

A chapter is devoted to specific diseases, to the means of infection
and their results.

The book, which deals with a difficult subject, is full of valuable
information and is written in a simple manner. It is one which should
be in the hands of all parents and guardians of young people.

Advanced Suggestion (.Neuro-induction ). By Haydn Brown, L.R.C.P.

Edin. London : Bailli&re, Tindall & Cox, 1918. Pp. 342.

That suggestion is a valuable method of treatment which is not made
use of in as many cases as it should be is slowly being recognised.
This seems to be borne out by the very large number of books on the
subject which have appeared recently.

The “ technique ” which Haydn Brown employs, but which is not
described, is referred to as being of a simple character.

Hypnotic suggestion is not recommended because the will-power of
the patient is merely in a state of obedience, while by neuro-induction
the will-power is steadily increased. The author states that the best
results are obtained only with the co-operation of the patient in this
method of treatment. He maintains that the sexual factor in mental -
disorders is not nearly so important as Freud believes, and he advises
that the word, association test should not be adopted in the diagnosis or
treatment of these conditions.

Reference is made to a very large number of clinical cases treated by
Haydn Brown. In many of them excellent results would be expected,
but there are others, both medical and surgical, in which the cures must
be considered remarkable.

It is unfortunate that so many new terms are introduced into the
book as they tend to lead to confusion. The omission of a description
of the technique employed considerably detracts from the value of
the book as a practical guide to treatment. Curiously works of this
nature frequently suffer from this defect.

Part III.—Epitome of Current Literature.

1. Psychopathology.

Shakespearfs “ Othello ” as a Study of the Morbid Psychology of Sex.
(.Nineteenth Century , fune , 1919.) Sullivan , IV. C.

Othello has usually been viewed as a tragedy of heroic love rather
than as a tragedy of insane passion, which the writer contends is
probably the correct interpretation. Definite indications are afforded
in the play of the pathological temperament of Othello, and it is
suggested that Iago, who is depicted by Shakespeare as inhumanly

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wicked and supreme in evil, is used in the play as the dramatic repre¬
sentation of morbid passion. He is not an actual human personage,
but he represents the projection of the insane thoughts and impulses of
Othello ; he is the dramatic device for showing the growth of diseased
passion in the mind. The gross sexual imagery in the speeches of Iago
are those which express the condition of a jealous lunatic. Just as
Hamlet’s hatred is crystallised by the confirming voice of the Ghost,
and the subconscious stirring of ambitions in the soul of Macbeth are
dramatically presented in the prophecies of the witches, so the growth
of morbid jealousy in Othello expresses itself in gross sexual thoughts
of hallucinatory intensity projected into the inhuman figure of Iago.

H. Devine.

a. Clinical Psychiatry.

General Paralysis among the Jews [.Die Paralyse der Juden in
Sexuologischer Beleuchtung\. (Zt. f. Sexualwiss ., June , 1919.)
Sichel, M.

Until recent times general paralysis has been rare among Jews.
Then it rapidly increased until it affected a fifth of the Jewish inmates
of asylums. In the last decade this proportion has slightly fallen, but
the fall appears to be apparent rather than real, as Sichel here explains.

What are the causes of this sudden development of general paralysis
among Jews ? Zollschen believes that syphilis works more virulently on
Jews because they were previously so free from it. Sichel finds diffi¬
culties in this explanation, and attaches more importance to the growth
of large cities and the confinement of Jews in such cities, with the
manifold opportunities for sexual excesses thus opened to them. In
nearly all large cities there is a special prevalence of general paralysis
among Jews as compared with the general population. Sichel quotes
figures for Vienna, London, and Frankfort. In rural districts, on the
other hand, general paralysis is extremely rare among Jews. The
spread of the disease is evidently dependent on urban life, and it is
suggested that the results of the war, which have led to the cry of “Back
to the plough ! ” even among Jews, will in this respect be beneficial.

The author remarks that his thesis concerning the connection
between the Jewish attraction to urban life and the special prevalence
of general paralysis may seem to be shaken by what is witnessed in
Russia. There the Jews are exclusively town-dwellers, for they had not
been allowed to be anything else, yet general paralysis is very rare
amongst them. This Sichel attributes to the thorough manner in
which the eastern Jews still exercise their traditional rites and customs.
The unfavourable political conditions which have led to their doing
this have been one of those forces which “ willed evil and produced
good.” The eastern Jews have? been enabled to retain their vital
energy uncontaminated, and as we pass from east to west we find an
ever-decreasing neglect of traditional observances, and, concomitantly,
an ever-increasing prevalence of general paralysis.

This result has, however, been powerfully aided by the custom of
early marriage among the eastern Jews—a custom which has decayed in

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the west owing to the increasing difficulties of living. We may expect
that, in this respect also, the war will be influential. The care with
which Jewish families surround young girls has been largely maintained
in the west, and that is probably the reason why the prevalence of
general paralysis is only among men, Jewish women being remarkably
free from it.

A further factor is found in the increasing abuse of alcohol among
the Jews, who formerly tended to be abstemious. Sichel finds that in
his own observations 17 out of 127 Jewish general paralytics had
had alcoholic tendencies, though the abuse of alcohol had been rare
among some 840 other Jewish asylum inmates; “there is a certain
connection between alcohol and general paralysis.”

It is also noted that Jewish general paralytics in the great majority
belong to the commercial class, and in their daily life had many oppor¬
tunities for acquiring syphilis. Of late, however, it is found that
general paralysis is extending to other Jewish social circles, and that it
is no longer rare among artisans. Havelock Ellis.

A Proposed New Classification. (The Mechanistic Classification of
Neuroses and Psychoses produced by Distortion of Autonomic
Functions'). iff ourn. Nerv. and Ment. Dis., August, 1919.)

Kempf, E. J.

The author, who is Clinical Psychiatrist at St. Elizabeth’s Hospital,
Washington, here proposes a new classification of the psychoses and
neuroses based on the view that “the same forces which build up a
personality when harmoniously integrated cause its deterioration when
unadjustable conflicts occur.” Modem psychiatry, he believes, needs
an elastic adaptable hypothesise direct terminology, a simple comprehen¬
sive method of classifying cases. The Kraepelinian system fails because
it Is fundamentally on a static basis, emphasising symptoms and
prognosis. Symptoms are grouped into circumscribed entities of
disease, despite the fact that in a large proportion of cases the sym¬
ptoms are classifiable into two, three, or even more groups, such as
neurasthenia, manic-depressive or dementia prsecox types, while about
half the cases are, at one period or other, atypical. There is thus
nothing to do but dogmatically to force the most suitable diagnostic
term on to the case for statistical purposes.

It seems to Dr. Kempf, therefore, more practical to classify psycho¬
paths according to the nature of their autonomic-affective difficulties
and their attitude towards them, because this keeps the dynamic
factors directly in psychiatric attention and permits of revision as the
symptoms change. The system of terminology here proposed relates
to the essential mechanistic factors that make a case curable or incurable,
and an important distinction is made between benign and pernicious.
“Benign” means that there is “a tendency to accept the personal
source of the wishes or cravings which cause the distress or psychosis ”;
“ pernicious ” means that there is a tendency to refuse to accept the
personal source of the wish or craving, tojiate those who attribute a
personal source, and to blame some external or impersonal source.

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There are five groups in the system: (1) Suppression neuroses , with
clear to vague consciousness of the ungratifiable nature of the affective
cravings, and distressing hyper-tensions or hypo-tensions of autonomic
(visceral) segments, (a) Repression neuroses, with vague to total uncon¬
sciousness of the nature of the influence, and the symptoms of the first
group, augmented by functional distortion of the projecting apparatus
and changed reactivity to sense-organs. (3) Compensatory neuroses, with
persistent striving to develop power and control and win esteem due to
the fear of losing them, usually accompanied by some of the same
symptoms found in the previous groups, with additional compulsions
and inspirations to strive for favourable conditions, resulting in all sorts
of eccentric attitudes, and on the physical side increased muscular
tension, high blood-pressure, tachycardia, exophthalmic tension, hyper¬
active thyroid, adrenals, etc., glycosuria. These three groups are
benign; the next two are pernicious. (4) Regression neuroses, with
failure to compensate, but return to an earlier more comfortable irre¬
sponsible level, permitting wish fulfilling fancies, postures, and indul¬
gences—together with persistence of attitudes belonging to the child
stage and general inefficiency and depression. Lastly (5) Dissociation
neuroses, where uncontrollable cravings dominate the personality and
there are distressing visceral tensions and all kinds of sensory and
social derangements.

The author fits the old diagnostic terms into this new framework in
ways that can usually be guessed, but the commonest of the current
types—manic-depression, dementia praecox, hysteria, etc.—fall into two
or more of the groups. It will be seen that the term “ psychosis ” is
dropped altogether, on the ground that “ the sensory phenomena which
we are conscious of as thoughts and wishes are the result of integrative
physiological processes, and the term * neurosis ’ is more consistent
with the integrative functions of the nervous system." No reference is
made to the psycho-analytic school of thought, or to the work of
Sherrington, Cannon, and Crile, but the inspiration of this classification
is sufficiently obvious. The author observes that it is only to be
considered “ experimental and suggestive," but he has himself found it
useful. Havelock Ellis.

Concerning “ Constitutional Ccencesthopaths ” [A proposito di “ Cenesto-
patici Constituzionali ”]. {Arch, di Ant hr op. Criminate, vol. xxxix,
fuse. 3-4, 1918-1919.) Lattes Leone.

The term “ constitutional ccenjesthopathy ” was suggested by Prof.
Buscaino ( Revista di Patol. Nero, e Mentale, 1918), as a useful de¬
nomination for a group of symptoms of emotional origin met with in
patients who came under his observation in military practice, especially
in connection with acts of misconduct—desertion, insubordination,
impulsive assaults, attempts at suicide and self-mutilation. Buscaino
observed that the majority of these individuals complained of anomalous
sensations referred to the viscera, and that they also presented objective
signs of disordered functioning of the sympathetic system, notably
exaggerated reaction of the pfelse to change of position, and disturbances
of the oculo-cardiac reflex. In the present paper Lattes, while not

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disputing the facts adduced by Buscaino, criticises, from the medico¬
legal point of view, his conception of constitutional coensesthopathy on
the ground that the disorders referred to are of frequent occurrence in
moral defectives and congenital criminals, and that in fact the military
offenders presenting these symptoms belong for the most part to the
category of the instinctive delinquent, and should not, therefore, be
allowed to escape the penal consequences of their acts on the plea of
being the subjects of nervous disease.

The point appears of rather academic interest except as illustrating
the greater prominence which the experience of the war has given to
the problem of the neurotic and border-line criminal.

W. C. Sullivan.

Dream-state due to Acute Exhaustion , with Psycho-analytic Note
[.Stato Sognante vero da esaurimento Acuto, con indagine Psico-
Ana/itica]. (Arch, di Anthrop. Criminate, vol. xxxix , fasc. 3-4,
1918-1919.) Marro , Giovanni.

This paper is a detailed report of a rather remarkable case of oniric
delirium. The patient, a man, aet. 32, was an Austrian official, lodging
with an Italian family in Alessandria, and subject as an alien enemy
to the usual measures of supervision.

On February 18th, 1916, as the result of a prolonged bout of sexual
excess, he got into a condition of pronounced nervous exhaustion with
rise of temperature, profuse sweatings, and absolute inability to take
food. These symptoms continued till February 25th, when he suddenly
got up, 16 ft his lodgings, and made his way to Turin, where he engaged
rooms and reported himself to the police authorities, telling a circum¬
stantial story to the effect that he had killed two persons at Alessandria
who had attempted his life for motives of vengeance because he defeated
their projects of usurious exploitation, that the judicial inquiry had
exonerated him on the ground that he had acted in self-defence, but he
had been advised to leave the town. The Turin officials telephoned to
Alessandria, and found that no such incidents had occurred, and the
patient was accordingly, in spite of his vehement protests, sent to the
asylum for observation. There he maintained the truth of his story,
and asserted further that shortly after his admission to the asylum he
was visited by his parents, who were enabled to come to see him because
peace had been made between Austria and Italy. In three days his
temperature fell to normal, the sweatings ceased, and he became more
reconciled to his detention. And after two days more he suddenly
announced that he had dreamt the whole affair.

At Marro’s request the patient wrote out a minute account of his
imaginary experiences, and from this document, supplemented by the
results of interrogation, it was established that the fantasies arose in a
series of connected dreams beginning on February 24th, and having
their apparent starting-point in a proposal, really made to him on that
date, to advance him a sum of money. Marro’s analysis satisfied him
of the existence of a painful emotional state due to the patient’s
unpleasant position as an alien enemy, to his financial difficulties, and
to his self-reproaches at being obliged to be a non-combatant at a

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moment of crisis for his country. The imagined acts of violence
symbolised his repressed wishes to fill a more bellicose rSle, and were
associated also with a disagreeable and very lively memory of youthful
indiscretions with moneylenders. VV. C. Sullivan.

3. Pathology of Insanity.

The Pathogenesis of Chronic Alcoholism [Sobra la pathogenesis de la
intoxication alcoholica ]. {Rev. de Criminol., Psiquiatria , y Med.
legale , Anno V, No. 26, 1918; reference in Arch, di Anthrop.
Criminale, vol. xxxix, fasc. 3-4, 1918.) DucceschiandBarilari.

From a clinical study of 121 subjects, including abstainers as controls,
and from a series of experimental researches, the authors state that
continued intoxication with ethylic alcohol in man and in animals
determines a manifest increase of cholesterin in the blood, which in
their view explains the generalised organic lesions met with in chronic
alcoholism. W. C. Sullivan.

The Blood Urea Nitrogen in Katatonia. {Journ. Nerv. and Ment. Bis.,
February , 1919.) Rappleye, IV. C.

Examinations of the blood were made before, during and after
semi-stuporose phases of katatonia. The cases chosen were mild ones
who ate during the period of examination, and the blood was taken
before breakfast, about twelve hours after a previous meal, so that the
food factor was eliminated as far as possible. Controls were carried
out on other patients haying similar diet, and the efficiency of the
renal function was ascertained in every case. The blood urea nitrogen
values showed a 50 per cent, or more drop from normal during the
semi-stuporose katatonic phase. The significance of this finding is
considered as probably due to lowered endogenous metabolism with
vasomotor hypotonia. Renal stimulation and incomplete protein
absorption from the intestines are considered as unlikely causative or
associated factors. F. E. Stokes.

4. Treatment of Insanity.

Modified Psycho-analysis in Borderland Neuroses and Psychoses.

{Psycho-anal. Rev., July , 1919.) Clark , Pierce.

For some seven years the author has made use of psycho-analytic
methods in borderland cases. He here briefly summarises results
which will later be set forth in full detail.

Seven manic-depressive cases came under consideration. In all it was
found advantageous to go carefully over the conscious and foreconscious
settings of the patient’s difficulties, especially those which seemed to
precipitate the periodic depressions. Dream production was mostly
found to have quite adult settings and not even latently sexual in
interpretation. Nor could analysis be pushed rapidly or completely
as in the hysteric neuroses, but dream interpretations had to be, as it
were, distilled. These periodic depressants seemed to demand mostly a

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common-sense re-formulation of their attitudes towards life-problems as
embodied in the marriage situations, with sublimation and substitution
for those not married. A psycho-analytic understanding of the patient’s
emotional life greatly helped this task. These patients exhibited but
little grit, courage, and perseverance, or hold on the basic realities
of life.

A similar essential weakness of the primary instincts of life was
revealed by “ mental torticollitics,” the individuals possessing an
intensely infantile emotional life with intellectual endowments below
those found in compulsion neuroses. The inversion required by psycho¬
analysis reduced them to impotence, and they had to be assisted towards
new developmental principles needed for adulthood.

Dementia praecox is usually seen too late for helpful psycho-analysis.
In such cases any pure application of it, the author believes, invariably
does harm. It takes away the crutches the patient has made and
reduces him to impotence. He should not be analysed, but receive
conscious suggestive therapeutics.

In conclusion, the author states, psycho-analytic methods should
only be used in borderline neuroses and psychoses with the greatest
care, but may be employed freely by the physician to enlighten his own
mind on the problems of the case he has to meet.

Havelock Ellis.

5. Sociology.

Sex Expression on a Lowered Nutritional Level. (J’ourn. Nerv. and
Ment. Dis., March , 1919.) Miles , IV. E.

There appear to have been so far only fragmentary data in existence
concerning the effects of under-nutrition on the sexual impulse. Some
interest, therefore, both theoretical and practical, attaches to a study of
the effects of prolonged restriction on diet lately carried out at the Nutri¬
tion Laboratory of the Carnegie Institution in Boston. The inquiry into
sex effects was a by-product of the investigation, and it is believed that
the influence of suggestion may be for the most part excluded.

Two squads of students, all young men and one married (“a clean
group of honest, virile fellows, with no venereal disease ”), were selected,
twelve in each squad, the second squad being for control purposes, and
put under a restricted diet, approximately two-thirds to one-half of their
supposed caloric requirements, during a period of four months. The
main results were a reduction in basal metabolism of 18 per cent, per
kilogramme of body-weight, lowered blood-pressure, and a drop in pulse-
rates but not in temperature. There was little decrease in neuro-muscular
co-ordination, no falling off in scholastic work, very little in physical
strength, and no apparent lack of vitality or efficiency or athletic vigour.

A few days after the termination of the experiment the inquiries
regarding sex phenomena were made of each man privately and indi¬
vidually. There had been no preliminary reference to this subject, but
the men were all willing to discuss the matter freely and fully. They
were warned of the possibility of fallacies due to suggestion or intro¬
spection. Their evidence gave the impression of truth.

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SOCIOLOGY.

Out of 23 of the students of whom the inquiry was made, 22 reported
a decreased general sex interest, the remaining 1 stating that there was
no change; 16 out of 22 stated that there was a decrease in the number
of nocturnal emissions, 6 observing no change, and none noting any
increase; 13 had observed a diminished frequency of erections, 4
observing no change in this respect; 9 found the desire for association
with the opposite sex diminished; several reported that the sex appeals
of dances, social occasions, picture shows, stories, etc., were diminished;
the married man, it may be noted, used the term “unsexed” to describe
the effect of the low diet on himself. At the time of the inquiry, about a
week after the end of the experiment, many w'ere already experiencing
a return of normal sex desires and activities under an unrestricted
diet.

Miles remarks that these results confirm the supposed connection
between sex and metabolism and agree with the results reached by
Riddle and others, who, studying the lower animals, find that sexual
activity is probably dependent on the metabolic level. Nature appears
to require a high metabolic level for purposes of race propagation.

The author remarks in conclusion that the results also clearly indicate
a method of treatment for achieving restraint of sexual tendencies in
pathological cases of excess. Havelock Ellis.

The Berlin Institute of the Sexual Sciences \Der Institut fur Sexual-
wissenschaften in Berlin\ (Zt. f Sexualwiss., August, 1919.)
Bimbaum , K.

Dr. Bimbaum here describes the aims and constitution of this
institution, founded by the generous efforts of Dr. Magnus Hirschfeld,
and opened last July in a building that was formerly the residence of
Prince von Hatzfeldt and previously of the famous musician Joachim.
(A later and longer account of the Institute appears in the fahrbuch fur
Sexuelle Zwischenstufen , Bd. xix, Heft 1 and 2). It is the first
institute of the kind to be established anywhere in the world. Its
functions are double—in the first place for investigation, and in the
second place for treatment and clinical teaching. As an institute for in¬
vestigation there are four departments : (1) Sexual biology, dealing with
such questions as the chemistry of the endocrinic glands, heredity, etc.;
(2) sexual pathology, dealing with variations, etc., closely in touch with
the practical medical side of the Institute and possessing a museum which
is already rich in varied material; (3) sexual sociology, for dealing with
the relations between sex and society, eugenics, marriage, prostitution,
sexual hygiene, etc.; (4) sexual ethnology, including the manners and
customs of different ages and peoples, and the influence of sexuality on
civilisation. The practical medical side of the Institute is also divided
into four departments : (1) For giving advice to those about to marry
or to choose a profession ; (2) a psychopathic department; (3) a depart¬
ment for psychic sexual troubles, as of potency, etc.; (4) disorders of
the genital organs. There are also a laboratory for analyses, and instal¬
ments for psychotherapy, organotherapy, electrotherapy, photography,
etc.

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64 NOTES AND NEWS. [Jan.,

In his inaugural address Hirschfeld spoke of the Institute as “ a child
of the Revolution,” and destined to aid in the restoration of the place
which was “ lost through fatal errors inside and outside of the frontiers
of the country.” The Institute is already at work with clinical demonstra¬
tions to medical men every week, courses of lectures on forensic
sexology and on Freudian psycho-analysis, and frequent scientific lectures
to the general public. It is stated that over 500 physicians from
Germany and abroad have already visited the Institute. It is not a
State-supported institution, but the belief is expressed that it will not be
the less successful on that account. Havelock Ellis.

Part IV.—Notes and News.

MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN

AND IRELAND.

The Quarterly Meeting of the Association was held in the Rooms of the
Medical Society of London on Tuesday, November 25th, 1919, Dr. Bedford
Pierce (President) in the chair.

The following signed their names in the book as having been present at the
meeting or as having attended meetings of committees : Drs. M. A. Archdale, Sir
Robert Armstrong-Jones, W. H. Bailey, W. R. Barkas, J. J. G. Blandford, C. H.
Bond, David Bower, A. Helen Boyle, James Chambers, G. Clarke, R. H. Cole,
Maurice Craig, J. Harvey Cuthbert, A. Daniel, H. Devine, J. Francis Dixon, R.
Eager, J. H. Earls, F. H. Edwards, Samuel C. Elgee, A. E. Evans, C. W. Ewing,
E. L. Forward, Claude F. Fothergill, S. G. Gilfillan, T. S. Good, W. J. H. Haslett,
H. E. Haynes, S. J. Irwin, G. H. Johnston, J. H. Kidd, H. Wolseley Lewis, E. S.
Littlejohn, J. R. Lord, H. C. Macbryan, H. D. MacPhail, W. F. Menzies, Alfred
Miller, F. W. Mott, Alex. W. Neill, David Ogilvy, E. S. Pasmore, George E.
Peachell, Bedford Pierce, J. E. Porter Phillips, Nathan Raw, J. M. Rutherford,
G. H. Savage, G. E. Shuttleworth, J. H. Skeen, G. W. Smith, T. W. Smith, J. G.
Soutar, P. Spark, R. H. Steen, R. C. Stewart, James Stewart, D. G. Thomson,
John V. Tighe, A. H. Trevor, C. Molesworth Tuke, L. R. Whitwell, C. E. C.
Williams, and Reginald Worth.

Visitors: Miss Branch, I. N. Kilner, F. W. Thurnman.

Present at Council Meeting: Drs. David Bower, A. Helen Boyle, James
Chambers, R. H. Cole, Maurice Craig, A. W. Daniel, R. Eager, H. Wolseley
Lewis, Joh n R. Lord, W. F. Menzies, Alfred Miller, G. E. Shuttleworth, J. H,
Skeen, R. H. Steen, and D. G. Thomson.

Apologies for unavoidable absence were received from—Drs. Stewart Adair,
G. E. Auden, Aveline, Fletcher Beach, Col. Keay, Douglas McRae, Robertson,
Donald Ross.

The President said, in reference to the question of the confirmation of the
minutes of the last meeting, that they were in print, but the Journal containing
them would not yet have reached the hands of members. He therefore suggested
that, in case anything should arise concerning them, they be left until the next
meeting.

Report on Deputation to Ministry of Health.

The President said he had been asked by the Council to say a word on this
subject. The deputation from the Association to the Minister was a strong one,
consisting of officers of the Association, the Chairman and Secretary of the
Parliamentary Committee, Dr. Helen Boyle and Dr. Percy Smith, and altogether
it was thoroughly representative of the Association. They were very kindly

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received by Dr. Addison, the Minister of Health, who was supported by Sir
George Newman, Sir Robert Morant, and by Dr. Maurice Craig, Adviser to
the Board. The deputation presented the resolution which was approved by the
Annual Meeting of the Association at York, and, following it, a very interesting
and confidential discussion took place. But they found at the outset—which was
news to them at the time—that it was the intention of the Ministry of Health,
directly Parliament opened, to place on the table of the House of Commons a
petition for an Order in Council which would transfer the Department of the
Government under which the Board of Control acts from the Home Secretary to
the Ministry of Health. It was the intention that this Order in Council should be
obtained at the earliest possible moment. Had the Council of the Association
known of this intention beforehand, he thought that in all probability the resolution
would not have been required, nor would it have been submitted to the Annual
Meeting, because that was the main burden of the resolution—that the control of
lunacy administration, the control of mental defectives and of borderline cases
should all be under the Ministry of Health. It was a pleasant surprise to find that
the main object of the deputation had already been attained. Thus there remained
little more for him to report to this meeting, except that a frank discussion ensued
on various points arising in the consideration of this matter. And though the
Health Minister could not give a definite answer to the questions put to him, their
reception was very kindly, and the members of the deputation felt they had had a
useful opportunity of discussing the problems of lunacy administration.

Items from the Council Meeting.

There were several questions discussed at the Council Meeting just held which
it was desirable to mention. The first was, that he was pleased to say Sir James
Crichton-Browne had consented to deliver the first Maudsley Lecture under the
Maudsley Bequest. It was proposed that this lecture should be delivered at the
time of the Association’s meeting in May.

The question of the Editors of the Journal was also discussed. It was the
intention that in future there should be four Editors : Lieut.-Col. J. R. Lord, Dr. H.
Devine, Dr. G. Douglas McRae, and Lieut.-Col. W. R. Dawson. The Council
had approved of that course, and unless this meeting should express anything to
the contrary those names would be printed on the front page of the Journal as
Editors in future. He felt sure there would be a conviction that the Journal would
be well conducted at their hands.

The Council also felt that the position in regard to the registration of nurses was
becoming a very serious one. They had been informed there was every possibility
that there would be a Supplementary Register for mental nurses, and there was
every possibility that the examination conducted by this Association would be
recognised as a means of registration. If this should be carried out by the Ministry
of Health, he thought it would be most satisfactory. The question was also raised
as to whether it would not be important that, somehow, it should be arranged for
mental nurses to be nominated on the Advisory Council of the new Bill. They
knew of no machinery for the appointment of such nursing members, and it was
decided to endeavour to arrange, through the Asylum Workers’ Association, that
two names of their members should be submitted—a male nurse and a female
nurse—and it was thought that the best way to arrange this would be that all
asylums and other institutions in which qualified mental nurses were now working
should receive a circular from this Association, asking them to call meetings
immediately of registered nurses in their respective institutions, and, if possible,
that these meetings should approve of the nominees of the Asylum Workers'
Association. It seemed extremely important that no time should be lost, otherwise
there was a danger that mental nurses would not be represented, as such, on the
governing body of the new Bill. He did not know whether any member of the
Association would like to make observations on this matter.

Lieut.-Col. D. G. Thomson asked why the Asylum Workers’ Association was
brought into this matter at all. They had great respect for that body, but it was
now practically moribund.

Dr. Soutar said he believed the answer to the remark of Col. Thomson was that
the representative of the nurses must be nominated by an organised body; that

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was a condition laid down. No organised body of mental nurses generally was in
existence except the Asylum Workers’ Association, which, though dying, was not
yet dead. And it was thought that at all events this final effort should be made to
secure the nomination of nurses for the Council under the Bill. If that were
accepted by the nurses throughout the country, then an organised body would
have nominated four members to the proposed Council.

The President said it would be a recommendation to the Minister of Health,
for that Ministry would make the appointment, and this would come merely as a
suggestion to that Minister, putting forward the machinery through which suitable
names could be submitted.

Dr. Soutar further remarked that this Association would be represented on that
Council, and names would be submitted.

Dr. Elgee said he thought many mental nurses would not be represented by the
Asylum Workers' Association.

Dr. Edwards said he did not know whether the Council had information about
the presentation of the new Bill. He believed the Registration of Nurses Bill
came up before the Summer Session and was rejected. It was now desirable that
these meetings should he held as quickly as possible all over the country, because
when a Bill had once been launched it was very difficult to get amendments incor¬
porated.

The President said the steps being taken by the Association had the full
approval of Col. Nathan Raw, M.P., and he would give them all the support he
could. The question was asked whether this Association was to be represented on
the new Council, and he had been honoured, as President of the Association, by
being asked to let his name be submitted to the Minister, so that, subject to the
Minister’s approval, it might be one of five names put forward.

Dr. Bower and Dr. Soutar insisted that the President’s name was suggested
for personal reasons, not because he happened to be President this year.

The President said the Council had asked him to refer to yet another matter,
namely, the desirability of awakening interest in the Association on the part of
medical men throughout the country to the important work which this Association
was doing. It had been decided to prepare, in the course of a few weeks, a memo¬
randum, which would be sent round very widely, suggesting that assistant medical
officers and medical men associated with pension boards and with the neurological
department of hospitals should be invited to join the Association, or if they had
once belonged to it to rejoin it now that the war was over and the Association’s
activities were recommencing in a more vigorous fashion.

Obituary.

The President said it was his sad duty to refer to the death of three valuable
members of the Association.

In the first place he would mention the death of one of the Editors of the
Journal, Dr. Drapes. He had been an exceedingly valuable and active member,
and he had set all a wonderful example of regular attendance, as he came frequently
from the south of Ireland to attend the meetings, and he had done an immense
amount of unseen work in helping forward the Association, both as regards the

J ournal and the Education Committee. He was present at the last Annual
leeting of the Association, taking an active part in the proceedings and partici¬
pating in all the proceedings, and he (the President) had received a letter from
Dr. Drapes afterwards, in which he spoke very warmly of the happy time he had
in York. He believed it was correct to say that Dr. Drapes caught a chill while
he was actually engaged in the work of the Association and the Journal, and after
two or three days of illness he died of pneumonia. He was sure all members
would greatly deplore his loss.

The next death he had to refer to was that of their illustrious member, Dr.
Mercier. All the time that he (Dr. Pierce) had been a member of this Association
Dr. Mercier had been one of its foremost and most active members. He had been
President, and for nineteen years he was closely associated with the Education
Committee, first as Secretary, afterwards as Chairman. He believed Dr. Mercier
was the first person who wrote a book on the subject of nursing the insane, and he

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helped in the compilation of some of the early editions of the Association’s Hand¬
book. Throughout his life he took a deep interest in the question of nursing.
It was on this account that he (the speaker) asked Dr. Mercier to give one of the
opening lectures at "The Retreat” to the nurses there, and he delivered an
address which was really a masterpiece of exposition on the principles required in
nursing mental cases. That address had since been published, and he hoped
members had read it. It dealt not only with mental nursing, but with the principles
required for all who were attending on the sick. A man who had written so much
haa left behind him such vivid testimonies of his worth and character that any
remarks which a friend or disciple could make were, perhaps, of small moment.
Yet there were two particular features of Dr. Merger's life to which he would like
to make brief reference. The first was his capacity for taking pains and his perse¬
verance. It was a surprise to him (the speaker), and perhaps to others, also, that
Dr. Mercier commenced life in a very hard school. He left school life quite early
and went to sea. Afterwards he was a warehouseman in the City. Though in
straitened circumstances he contrived to join the London Hospital, and when he
reached his twenty-sixth year he was a Fellow of the College of Surgeons. He had
a distinguished career and became an eminent man. Those who were familiar
with his writings—and all the members of this Association were familiar with
them—might have supposed it was an easy matter for him to write, but Dr. Pierce
had a letter from him, from which he would like to read to the meeting an extract :
44 Writing, as Clifford Allbutt calls it, is the supreme art. The only way to write
is incessant and careful practice and everlasting revision. I have written my book
on Logic already about seven times, and am now again beginning Chapter II, and,
of course, all the succeeding chapters must be once more re-written. But, of
course, the subject is one of exceptional difficulty.” That book on logic had now
been published, and though the professors on that subject possibly did not give it
the reception which Dr. Mercier expected them to, yet he thought it would stand
the test of time.

The other outstanding attribute of Mercier’s life was his fortitude. It was known
to many members that Mercier was obliged to give up active medical work on
account of a progressive, painful and exhausting illness. It was at about this time
that he gave the lecture to the nurses of "The Retreat,” to which reference had
already been made, and at about that date Dr. Mercier wrote to him a very sad
letter, in which he said, 44 1 am no better in health, and never shall be ; I get worse,
week by week, and long for a release from a life of misery.” This was not just the
remark of a person in a moment of depression. It was wrung from a man racked
with bodily suffering. When Dr. Mercier gave this lecture he could scarcely stand
during the hour that it occupied, and he (the speaker) knew how much the lecturer
suffered while he was giving it. He received a letter from Mercier’s devoted sister
after the former’s return from York, in which she wrote, “ I am sorry to say the
inevitable reaction has set in ; to-day he is prostrate with fatigue and complains of
faintness ; but his life, at best, is such a sad one nowadays that I cannot think that
the pleasure which these little outings give him is too dearly bought. He has so
little to enjoy, and as he sometimes has these fits of prostration and languor without
any apparent reason I think it is wise to keep going while he can, even at the price.”
And Dr. Mercier did " keep going ” for another ten years, and he was sure mankind
had been the richer for his fortitude. Perhaps there was no need to say more than
to conclude by reading the last sentence of his address to the York nurses : 44 Not to
everyone is it given to govern empires, to explore unknown lands, to discover the
secrets of Nature, to enrich nations by some great invention ; but we can all do well
and truly the work which lies to our hands ; we can all contribute to make the lives
of those around us happier and better ; we can all live so that at the inevitable hour
when we have to bid farewell to this earthly scene, many will sorrow for our loss,
and we can feel, with thankfulness, that the world is even a little happier because
we have lived, even a little better for our example.” We mourn his loss.

And the third death he had to refer to was, perhaps, even sadder, namely, that
of Dr. Fearnsides, for he was cut off in the midst of an active life at the full
measure of his strength. A neurologist of great power, he died as the result of a
boating accident. Members deeply sorrowed at his loss, and grieved that he could
no longer carry on the great work in this world which he was undertaking.

It would, he felt sure, be the wish of members to express their sympathy with

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the surviving relatives of their departed members, and he asked that this be
approved by standing.

The resolution was carried by members rising in their places.

Election of Candidates for Membership.

The following were elected :

Branthwaite, Robert Welsh, C.B., M.D.Brux., M.R.C.S., L.R.C.P.,
D.P.H.Lond., Commissioner of the Board of Control, 66, Victoria Street,
London, S.W.

Proposed by Drs. Sidhey Coupland, C. Hubert Bond and Arthur
Rotherham.

Blakiston, Frederick Cairns, M.R.C.S., L.R.C.P., Medical Superintendent*
Isle of Man Asylum.

Proposed by Drs. Edwyn H. Beresford, P. M. Turnbull and R. Worth.

Johnston, Millicent Hamilton, B.A., M.B., B.Ch., T.C.D.. Assistant
Medical Officer, Brentwood Mental Hospital.

Proposed by Drs. J. Turner, J. Noel Sergeant and Adele I. de Steiger.

Westrup, Joseph Percival, M.R.C.S.Eng., L.R.C.P.Lond., M.O. Fisherton
House Mental Hospital, Salisbury.

Proposed by Drs. H. Kerr, H. Devine and T. C. Shaw.

Wheeler, Frederick F., M.R.C.S., L.R.C.P., Assistant Medial Officer, Long
Grove Mental Hospital, Epsom, Surrey.

Proposed by Drs. D. Ogilvie.R. H. Cole and R. Worth.

Gifford, John, B.A., M.B., Ch.B., Senior Assistant Medical Officer, Derby
County Asylum, Mickleover.

Proposed by Drs. H. Devine, F. E. Stokes and R. Worth.

The scrutineers were Dr. Steen and Lieut.-Col. Lord.

The Association’s Finances.

Dr. Worth said that during the meeting at York a discussion arose on the
Treasurer’s Report, and it was decided that a special Sub-Committee should be
formed to consider the financial position and report to the Council. This Sub-
Committee consisted of Dr. Bedford Pierce, Dr. Chambers, Dr. Menzies and Dr*
Worth, and tiie Divisional Secretaries. After a good deal of discussion they
arrived at three decisions. The first was that the annual subscription should be
raised to one and a-half guineas, especially to meet the extra cost of producing the
Journal. Members would remember Dr. Drapes pointing out how high had been
this cost, and that endeavours would be made to procure other prices. There
were, however, objections to this course, and it was decided to approach Messrs.
Adlard with a view to getting some reduction in the cost of the printing,etc. Also,
it was considered that all medical superintendents should be approached with the
idea of extending the Association’s propaganda among medical officers, to encourage
them to, if possible, take more interest in the Association's activities. Indeed, it
was suggested that it should be an understood thing that every medical officer
appointed in an asylum should be a member of this Association. The last
suggestion was to encourage the sending in of ideas with regard to brightening
and improving the Journal.

Revision of the Mental Nurses’ Handbook.

The President said the Education Committee decided that the time had
arrived when the Handbook for mental nurses should be revised. They were
taking preliminary steps to appoint an Editing Committee. He mentioned the
matter now, so that when the time came members might be prepared with
suggestions. He hoped suggestions would be forthcoming, so that not only would
the Handbook be improved, but would be worthy of the Association.

He regretted that Major Shaw had been obliged to withdraw his paper, as the
India Office had not passed it.

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Paper.

Dr. Charles Hubert Bond (a member of the Board of Control) read the
following paper: “ The Need for Schools of Psychiatry” (vide p. 10.).

The President said members felt greatly indebted to Dr. Bond for giving this
admirable survey of the subject. There were several in the room who had served
on committees which had dealt with the subject. It was a great advantage to
have the points so clearly put forward, pointing the way for advance. They
realised the enormous number of military clinics which had been established had
created a new situation and now was the time for making a permanent improve¬
ment.

Lieut.-Col. Lord said the subject which Dr. Bond had just brought before the
Association was one of vast importance. He took it that the paper aimed at the
more thorough treatment of patients with a view to their cure. People suffering
from mental trouble were too frequently looked upon as a class apart from indi¬
viduals who suffered from ordinary bodily ailments. Such views should be
vigorously opposed. Lunacy was essentially a medical matter and not a social
disease, though, like all medical problems, it was important socially. Efforts
should be concentrated on curing mental disease, not merely reclassifying the
unfortunate patient in an isolated category of the scale’ of humanity. It was most
desirable that specialism with regard to the treatment of mental diseases should be
encouraged far more in the future than it had been in the past. He mentioned
that the war had taught the profession many things in this respect, and it was only
through the concentration of the best efforts and by special administration that
the immense progress in the cure of many diseases and injuries incidental to or
exacerbated by warfare had been effected. These methods could well be considered
in connection with mental diseases. The medical effort in psychiatry was too
wide-spread and diffuse, and resulted in too much general knowledge to the exclu¬
sion of special knowledge of particular groups of mental disorders. It could not be
helped Jit present, but until this was remedied no real progress could be made.
There seemed to be no reason why mental and nervous diseases should not be
divided up into clinical groups and concentrated effort made to cure them at
different specially-administered centres for each. The scheme now so ably put
forward by Dr. Bond would directly help to that desirable result. By the Univer¬
sities he felt sure such ideas would receive strong encouragement. The psychia¬
trist’s ambition is undoubtedly to cure insanity, but to secure this it is folly to
undertake too wide an area, and he should limit himself to cure certain forms of
insanity and allied nervous conditions and not waste his energies, as at present,
with impossibilities. He felt very strongly about this aspect of the subject and the
poor progress that was being made under present conditions.

Lieut.-Col. D. G. Thomson said that as Dr. Bond had mentioned his name as
one who had helped to bring this subject forward ten years ago he would like to
say a few words. His friend Col. Lord had referred to 'the advisability of this
reform, but he (the speaker) hoped they had gone long past that: they were now
all united in the belief that things as they exist at present were not satisfactory,
and it was for those interested in the subject to see how a remedy could be
brought about. Dr. Bond had brought forward the matter in an admirable
way, and if that gentleman was glad to find himself back in the witness-box,
members of the Association, on their part, were delighted to see him back.
Hearing Dr. Bond’s paper for the first time, it struck him there were two main
points in it. In the first the author emphasised—and, the speaker thought,
rightly—the real direction in which workers should aim in this subject. It had
recently been recommended in some of the Committee work of the Association
that an endeavour should be made to establish mental clinics. As he understood
that work, it was to be rather local and special. What Dr. Bond had now brought
forward was a great improvement on that, namely, to approach the teaching
centres and even non-teaching hospitals to get them to take this subject up. It
would be very difficult to do so, as he believed that scarcely a hospital in this
country had not had painful experience of the occasional intrusion of a person of
unsound mind into the wards, and then they seemed to have experienced the terror
of being in a ship without a rudder. Real progress could only be made on these
fines, however difficult it might be to engineer the practical problems which would

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arise. The second rather new element in Dr. Bond’s paper was that concerning uni¬
fication, if possible, of the curricula that had been established, and this Association
ought to feel very proud of having succeeded in establishing such a curriculum, for
it came out of the inner bowels of the Association, by preaching to the great bodies
and getting them to institute diplomas. If those bodies could be approached so
that they would give to younger colleagues a more definite idea as to time and
cost in regard to these diplomas it would constitute a very practical advance.

Sir Frederick Mott, F.R.S., said he had been very interested to hear
Dr. Hubert Bond’s paper, and he reflected that forty years ago the London
County Council, at its inception, proposed the establishment of a hospital for
acute mental diseases in London. What became of that ? It would be interesting
to members of the Association if they would read the report on the subject. For
a long time nothing whatever was done towards establishing a mental hospital
with a clinic in London. If such had been established, it might by this time have
done very valuable work, and have attained to a high position in psychiatry,
similar to that occupied by the National Hospital in Queen Square in the domain
of neurology. He was glad to see that this Association had changed its views,
late in the day though it be, and that it had come to recognise the necessity of
such an institution. The late Dr. Maudsley, for whom members had the greatest
respect, came to him eleven years ago and offered to furnish the London County
Council with .£40,000 to build a hospital in London for the purpose of receiving
acute mental cases and for the study of psychiatry. It was a long time before the
London County Council could find a site, but they did so eventually. The hospital
was partly built when the war came, and he was sorry to say that neither
Dr. Maudsley nor Mrs. Maudsley—who was a daughter of the Conolly who took
the chains off lunatics in England, and Dr. Maudsley was better known in other
countries for his work than among his own people—neither of them ever saw the
hospital adapted for the purpose intended. That seemed to him to be a great
pity. But it had done useful work during the war, and for a time it was to be in
the occupancy of the Ministry of Pensions. The London County Council were
now anxious to get it back to the purpose for which it was founded—for dealing
with cases among the general civilian population. He did not think he was
committing a breach of confidence when he said it was hoped shortly to establish
a clinic at the Maudsley Hospital, in correlation with the asylums of the London
County Council, so that teaching could be carried out in all branches of psychiatry,
including the fundamental principles underlying the physiology, anatomy and
pathology of the nervous system, somewhat on the lines which Dr. Bond had laid
down in his paper. It was intended to get the best men possible in the country to
give such lectures. For instance, he hoped to get Dr. Macdougal, Dr. Bernard
Hart, Dr. Devine, Dr. Hubert Bond and a number of other men to give the
lectures. That course, it was hoped, would be open to all post-graduate students,
and all who were qualified in medicine. He thought it was essential that there
should be this correlation between the asylums and the Universities — if there
were a University town near. Both the University and the asylum would benefit
greatly thereby. In Scotland the University had always been associated with the
asylum, and he thought that Scotch graduates were better trained in psychiatry
than English students were. Tradition had for a long time acted in Scotland
beneficially in that way. For some time he was an Examiner in Medicine for the
Conjoint Board, and he found that the Examiners in Medicine seldom set questions
in mental disease, and consequently the classes in those subjects were rather
badly attended. He set a question on adolescent insanity, and, through the
kindness of Sir Robert Armstrong-Jones, he had two instances of it brought up—
typical dementia praecox. He, the speaker, was afterwards informed that the setting
of this question had a beneficial effect on the attendances at the classes in psychiatry.
Generally he tried to get a question in on the subject because he regarded it as very
important. It might be that after a student became qualified, one of the first cases
he would come against would be a mental one, and he would be at sea if he had not
had a training in the essentials of psychiatry. He would like to see established
clinical-assistantships, giving men six months’ experience, and he hoped to carry that
out at the Maudsley Hospital, to give men an opportunity to see whether they would
like to follow the speciality. With regard to the curriculum which Dr. Bond
laid down, life was short, and the extent of modern knowledge very great. He

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thought the system at Edinburgh was the best: there it was not hoped to cover the
whole range. He thought the best training for men who intended to become
medical superintendents of asylums was a good foundation in general medicine,
which included preventive medicine. For example, how important were deficiency
diseases in the treatment of the insane, the resistance engendered against
disease by a sufficiency of vitamines, and how detrimental their deficiency. With
regard to beri-beri, there were known to be two forms. One form did not give
any pronounced symptoms, yet there was a lowered resistance to infectious
disease. There was a great deal in being able to recognise a disease and knowing
what specialist to call in for its treatment. He congratulated Dr. Bond on his
paper, in which he laid down the right principles to adopt. Lastly, he wished to
say that when an appointment was made to a medical superintendentcy of an
asylum, it should be founded on his knowledge of the specialty, not because he
happened to be a good farmer, though he thought it needful and right he should
be head of the Institution.

Dr. R. H. Steen said one point about Dr. Bond’s admirable paper, which he
was sure all the members felt very grateful for, was that he was preaching to
the converted. All in that room realised the need for clinics in psychiatry. The
difficulty of those in the specialty was with the general physician and surgeon and
the staffs of general hospitals. They were the people who required convincing
that mental clinics were required. For many years he tried to get established an
out-patient department of this kind at a certain hospital with which he was con¬
nected, and from private talks he had with members of the staff of that hospital
he gleaned they had the idea that a mental patient was necessarily an acute
maniac; they had visions of acutely maniacal persons dancing up and down the
corridors. For a long time he was unable to succeed in his efforts, but such a
department had now been started, and the other members of the staff seemed very
thankful for it. He wished to urge that all teachers of psychiatry—and they were
all members of this Association—should make a point of getting established an
out-patient department for mental cases in connection with their own particular
hospital. He did not mean that they should be altogether satisfied with that, but
it would at least be a beginning—the thin edge of the wedge—and later on beds
could be set up. It would be found that students exhibited great interest in
mental diseases, and they were keen to come to the clinics. Members of this
Association could, if they would, do a lot of missionary work by urging physicians,
surgeons and consultants generally to insist on the establishment of these special
departments in psychiatry.

Dr. Myers said he would like to point out that a mental clinic had been started
at Cambridge. The staff there unanimously favoured the institution of an out¬
patient clinic, and, thanks to the generous spirit displayed by the Board of Control
and the Medical Research Committee, it was possible to send an expert there, and
he was now spending his whole time on the out-patient work and in conducting
research in psychological medicine. This was so recent that results could not yet
be given, beyond the fact that Capt. Prideau had written expressing a fear that
he might be swamped by the large number of cases and thus be prevented from
doing research work. Possibly some help could be supplied to him. Close asso¬
ciation was being established between Addenbrook’s Hospital and the Mental
Clinic at Filbourne, where the Medical Superintendent, Dr. Archibald, was in full
sympathy. At Cambridge the Diploma had not been accompanied by teaching ;
they had been content to allow candidates for the Diploma to take their courses
anywhere, provided they showed sufficient knowledge at the examination. But he
agreed with Dr. Bond that every teaching University should aim at providing
courses in this subject, so that the candidate possessing the Diploma would be
recognised as having passed through a certain school. Dr. Bond’s paper showed
the need of schools in psychiatry, and the more schools there were, with divergent
shades of thought, the better it would be for the advancement of the subject. The
Diploma was not instituted until 1912, therefore there had not been a chance of
doing much before the war, and the number of candidates had been very small.
During the war the Diploma had to be suspended altogether. The question now
was as to what could be done to encourage more candidates to come forward for
the Diploma. He felt that much could be done in the way of encouragement by
the authorities responsible for filling posts in mental hospitals, and by the granting

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of leave of absence to men for the purpose of study. But so long as mental
hospitals continued to be run 44 on the cheap,” so long would it he impossible to
provide facilities for post-graduate education.

Dr. Good (Oxford) said it might interest members to know that for two years
Oxford had possessed an out-patient clinic for mental cases in connection with the
Radcliffe Infirmary, and it was hoped that soon there would be some beds attached.
It was not given the name 41 mental clinic,” because that would deter people
coming to it. He had been working with Dr. William Macdougal for more than
two years, and that gentleman had, unfortunately, now retired. The work was
sufficient to keep one employed from 2 o’clock until 8, leaving practically no time
for research. People were coming in increasing numbers, and students were
taking a great interest in the work. At present there was no degree in psycho¬
logical medicine at Oxford, though the question had been mooted.

Dr. Devine said there was an international side to the question. Sometime
ago he was associated with an American unit, attached to which was a very clever
young neurologist. That officer told him he had been to Queen Square studying
neurology, he had been to Oxford and studied physiology under Sherington, and
he asked, 44 Where do you learn psychiatry in England ? ” He came from Boston,
U.S.A., where some fine work was being done. He had to reply to him, 44 1 do
not know a definite centre here, though there are a lot of able men of international
standing, and you could go to Wakefield Asylum and see my old chief, Dr. Shaw
Bolton.” For the sake of our own national credit we should have centres for
the clinical study of psychiatry and where it could be studied intensively. The
study had been pursued in this country by people under the greatest possible
difficulty, with little encouragement. Dr. Shaw Bolton, for instance, did wonderful
work in psychiatry, but who had followed it up ? There was no school, no centre
of instruction. Until centres were established for the intensive study of the
subject, so that the needs of those who intended to devote their lives to the subject
could be catered for, there would not be real progress in the specialty. Some said
psychiatry was a matter of psychology, some that it was a matter of chemistry,
still others that it was a question of pathological anatomy. His own view was
that it was not any one of these, but all of them. Until they could get at grips
with it in the proper way, until teachers, with students under them, could start
a tradition and a school, which would develop into a British School of Psychiatry,
he did not look for much real progress.

Dr. Peachel, commenting on Dr. Steen’s remark, said it was not so much the
physician and surgeon as the general public whose interest should be aroused in
this subject, chiefly through the medium of asylum committees. Therefore he
thought it would be a good thing if a prtcis of Dr. Bond’s paper could be sent to
the various medical superintendents of asylums so that they in turn could hand
it to their particular committees. When one was right in the country—as he was
himself—one realised the need of getting into touch not only with local medical
men, but also with the local hospital, even though it might be one of 100 beds or
less. In the way of propaganda very much could be done by that course, and the
public would benefit by having early treatment.

Sir Robert Armstrong-Jones remarked that, by the courtesy of Dr. Bond, he
had had an opportunity of perusing his paper beforehand as he had been unable
to arrive in time to hear it read. He considered it was a great advantage that
a man of Dr. Bond’s eminent position should come to the Association and speak
on this subject. He (the speaker) had recently been given an opportunity of starting
a mental department at St. Bartholomew’s Hospital, and he had been appalled at
the lack of knowledge on mental subjects displayed all round. Medical men
whom he had met frankly admitted they knew nothing about insanity. How was
that hiatus to be filled ? He thought a simple method would be to afford to every
medical man a chance of seeing in his own neighbourhood a case of acute mania,
a case of acute melancholia, of epilepsy, of general paralysis of the insane, of
arterio-sclerosis, which could in many cases be modified by treating the chronic
elements in it, such as the chronic constipation and dyspepsia. The last speaker
mentioned want of sympathy and knowledge on the part of the public. He had
himself spoken to people who were on asylum committees and they neither knew
nor apparently wanted to know much about the subject. He wanted to see some¬
body kindle an interest in the matter, and the Board of Control could do this by

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trying an experiment of a M field worker/* as in America, in one district. This
would undoubtedly kindle a public interest in the matter. When people talked
about *' mental hygiene/* what did they mean by that term ? They should be told
that there were two or three conditions which required to be studied in detail in
reference to the incidence of mental disease—alcohol, syphilis and the element of
heredity. He (the speaker) would like to see every medical superintendent giving
time to this matter in his own neighbourhood and foster the idea that the asylum
should be looked upon as the place where people can consult the medical staff. It
was very difficult for a senior man to keep himself up to date in cerebral physiology,
anatomy, chemistry, and so on, but the junior men could do so, and they would if
they were afforded the requisite encouragement by the authorities. They should be
allowed leave in order to study. But where were they to study ? What was needed
was coming by degrees. It was only recently that the Bethlem Royal Hospital had
started an out-patient department for cases, and St. Bartholomew’s, as he had stated,
was another example. It might interest members to hear what kind of cases had,
so far, attended the mental department at St. Bartholomew’s Hospital. They were
congenital epilepsy, some mental defectives, who had to be dealt with under the
Mental Deficiency Act, cases of dementia praecox, early cases of general paralysis
of the insane, involutional melancholia and manic-depressive insanity, but few of
the sex or Freudian abnormalities. Altogether he had been encouraged, and he
had the feeling that one could do something for these cases, especially if sleep
could be procured for them, and their constipation could be corrected and electric
treatment applied. He had seen much good done by cerebral galvanism in the
war neuroses at Aldershot. In climacteric trouble, too, static electricity had been
beneficial in modifying the blood-pressure. If possible the public must be educated
in this matter, and then he felt there would be a move forward to allow medical
men in the asylums to carry on this training. It was a deplorable fact that,
though five Universities had granted diplomas in psychiatry, there were not five
candidates at each, though of course the war had had a deterrent effect. This
paper, however, indicated a move in the right direction. If one could come into
touch with people at the home, the school and children’s courts, where mentally
deficient cases came to light because of small offences against social order, much
alleviating work could be done. The subject was a most important one.

The President said a letter had been received from Dr. G. A. Auden, of
Birmingham, stating how sorry he was that he could not attend, as he had hoped
to point out the desirability of making provision for the training of school medical
officers in the diagnosis of feeble-minded conditions. With regard to the
suggestion of Dr. Peachel, assuming that Dr. Bond’s paper would be published in
the Journal, the distribution of it to the quarters specified might be effected in
that way. * It had been decided, earlier in the day, that members of the Association
should receive from its officers a letter dealing with the question of propaganda,
and this letter could have incorporated in it a brief statement on this subject, and
pointing out the willingness of the Association to provide reprints of Dr. Bond’s
paper, if its author saw no objection, and these could be handed to members of
Visiting Committees. That would not cost very much, and the Treasurer had
said he did not think the expense of it would be prohibitive. [Col. Thomson : It
would be Greek to many of them in its present form; it would need translation
into ordinary language.] As there was no very decided expression of opinion
on that point, he thought it might be left over for the present.

Dr. Bond, in reply, desired to express his thanks for the very patient hearing
which had been accorded by members to his paper, and the great satisfaction
it was to him that the crude form in which the opinions had been laid before
the meeting had led to such a kindly and encouraging discussion. As the time
was now late, he hoped he might be forgiven if he did not do full justice to
what the several speakers had said. All were exceedingly glad to see Col.
Lord here. Members knew the immense amount of work he had been called upon
to do at the Horton County of London War Hospital, and some time ago it was
reported that he was far from well. He agreed with that gentleman that many
hard things were said about specialism, some of them, no doubt, just because
specialism without a good grounding in general medicine was all to the bad. In
the other way, however, it was to the good, and he agreed that concentration upon
small departments of their larger work would be the best means of making

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progress. He felt grateful for Col. Thomson’s remarks, also for the goodwill with
which the Colonel allowed him to take up the threads of his own pioneer work.
That speaker laid stress on the reluctance of general hospitals to confer facilities
for studying mental cases, and in that he was only speaking what was the fact.
But if staffs of hospitals based their experience upon the effect of one acute case
in their wards, that they should take up a hostile attitude on this question was
what one would expect, because the mixture of mental and general cases in the
same wards must be profoundly bad for both. One wanted to see them in wards
under the same great label as the wards for general cases, namely the name of the
general hospital in question. What Sir Frederick Mott said would surety give
them food for thought. Some of Sir Frederick’s comments sounded as if he took
some exception to the formidable nature of the diplomas; but he, Dr. Bond, laid
stress himself on not trying to teach too much detail, and upon concentrating upon
the “ institutes” of the required subjects. Therefore he felt that Sir Frederick and
he were at one on the matter. He was also glad Sir Frederick insisted upon
particular attention being paid, in whatever teaching psychiatrists were able to do,
to the relation of this branch to general medicine, an insistence which, if included
in any scheme—and there was a precedent in the case of the diplomas—would
probably abolish such terms, which he disliked, as “alienism” and “alienists.”
Dr. Steen declared that what the paper did was to preach to the converted^
He knew Dr. Steen was right in that remark, and in bringing this paper before
the Association it was with no such ideas as that the members stood in need of
conversion on these points. His hope had been that the reading of the paper here
might lead to some decision being taken—by way of the formation of a Com¬
mittee or any other means—again to carry out propaganda work in this and other
places where there appeared to be some stagnation. With regard to the idea of
Dr. Peachel that a precis of the paper should be printed and circulated to medical
superintendents with a view of it getting into the hands of members of visiting
committees and others, that was a flattering suggestion, but he thought there should
be pause before it was adopted, and that time should be taken for consideration as
to the best means of securing progress in our speciality. Still, whatever the
Association chose to do with regard to the paper was a matter entirely for them.
He desired to express his thanks to Sir Robert Armstrong-Jones for what he had
said. It was with great difficulty Sir Robert reached the meeting at all. It was
particularly interesting to know that a mental department had been founded at St.
Bartholomew’s Hospital, with all its ancient traditions. That gentleman was right
when he assumed that the object of the present paper was to kindle a wide interest
in the subject, not among members of this Association, but among the public. And
the point in the letter from Dr. Auden was important. He, Dr. Bond, was not
sure that the syllabuses of the different Universities granting the Diploma dwelt
sufficiently on the question of mental deficiency, yet it loomed so large now that it
might be well to press on the University authorities this Association’s opinion
as originally expressed in their memorandum—that there should be optional
subjects provided for in the Diploma conditions.

IRISH DIVISION.

The Autumn Meeting of the Irish Division of the Medico-Psychological
Association was held on Thursday, November 6th, 1919, in the Royal College of
Physicians.

Members present: John M. Colies, K.C., LL.D., in the Chair, Lieut.-Col. W. R,
Dawson, Drs. Hetherington, Gavin, Nolan, Greene, H. Eustace, Keane, Harvey,
Mills, J. O’C. Donelan, Rutherford, and Leeper (Hon. Divisional Secretary).

Before the business of the meeting was proceeded with, it was proposed by Dr.
Hetherington and seconded by Dr. Eustace :

*' That this meeting of the Irish Division of the Medico-Psychological Associa¬
tion desires to place on record its extreme regret at the loss which the Association
has sustained by the death of Dr. Drapes, who was one of its oldest and most
valued members, and this meeting expresses itself fully in accordance with the
action of the Hon. Secretary, Dr. Leeper, in sending, at the time of the sad event,.

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to the members of the deceased’s family a wreath and letter of sympathy in the
name of the Irish Division.”

The resolution was passed in silence, the members standing in their places.

The minutes of the previous meeting were read and signed.

It was proposed by Dr. Nolan, seconded by Dr. Mills and passed unani¬
mously :

“ That in the appointment of an Editor to the Journal of Mental Science , to
fill the vacancy occasioned by the death of the late lamented Dr. Drapes, the Irish
Division desires unanimously to place the name of Lieut.-Col. Dawson before the
Council as a suitable successor and as representing this country.”

Dr. Mills drew attention to the fact that the date of the Summer Meeting
fixed in 1920 would possibly interfere with the Annual Meeting of the British
Medical Association, and it was decided that the date fixed for the Summer
Meeting should again be considered at the next meeting.

Dr. Nolan next introduced his discussion upon “ The Irish Asylum Service and
Its Relation to the Ministry of Health Act.”

" I venture to introduce this discussion with some degree of doubt, as I am not
quite sure that there exists an Irish Asylum Service in a departmental sense, and
if there is, that it has any relation to the Ministry of Health Act, at least so far as
the Public Health Council in Ireland, as created under that Act, is concerned. In
any event, a discussion may help to throw light on many doubtful matters, and
possibly be the means of shaping a policy or plan of campaign, to enable this
Division of the Medico-Psychological Association to express reasoned opinions as
to the future of the Irish asylums, their patients, staff and administration, as well
as on allied matters of public health.

“ So far it would seem that the attitude of those responsible for the Ministry of
Health Act, beyond the mere statement in that Act, that it is to deal with ‘ the
treatment of mental defects/ has shown, as far as I am aware, no disposition to
put that clause into effect, and it is remarkable that the opening address of the
Chairman of the Health Council contains no reference to mental disease, nor does
the Council itself embrace any expert representation of the interests of the insane
and the general question of insanity, its prevention, increase, and efficient treat¬
ment.

" Possibly all this is being dealt with by the inspectors of lunatics in secret
treaty with the promoters of the Act. If so it is in good hands, and any action of
this Division will no doubt be in support of and accord with their proposal. But I
submit that the matter is one which should be handled openly and above board, and
in the first instance by those who have a practical everyday knowledge of the
public asylums. Hence, I venture to ask you to-day to consider what bearings
this Act may have on those institutions. Personally, I see great potentialities for
good, or for evil, and much must be considered before we can see clearly how to
secure the maximum of the good and the minimum of evil.

” I do not propose to read you any hard and fast conclusions, but simply to name
the points for consideration.

“(1) As to Insanity.

u Pathological research in laboratory work, now optional, to be made obliga¬
tory.

“ Treatment of incipient insanity by special expert advice, say at several centres
in each district.

“ Institutional treatment.

u Special specific treatment.

u Boarding-out. Now that conditions of life have improved and labour con¬
ditions are so difficult, more toleration would be extended to defectives received
into family care.

“(2) The Staff.

11 Its adequate pay and training. Its status as a nursing body restored by
making strikes without notice a criminal offence.

"(3) Administration of Public Asylums.

** Augmentation of the grant in aid. Adequate medical staff, with special aid in
matters of dentistry, etc.

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“ Other matters—as to the position and powers of the inspectors, etc., and legal
amendments to existing Act, as discussed at the Summer Meeting of the Division
at Downpatrick in 1918—might also be included in a Bill.

" It would seem to me, in any event, that it is the clear duty of this Division to
formulate a constructive policy of action in all these matters, in the event of any
legislative measures which may be proposed later. Any such policy should be
well considered.

11 1 would appeal to the members to treat the matter from a broad, unselfish
standpoint, keeping only in view as a goal whatever is in the best interests of the
afflicted insane.”

A full discussion followed Dr. Nolan’s opening statement, in which almost all
the members present took part. It seemed to be the general feeling that a strong
central controlling body co-ordinating the Irish Asylum Service in the interests of
the insane and standardising and improving the treatment and general manage¬
ment of asylums was urgently needed, and should be incorporated into any legis¬
lative measure dealing with the same. The various points of Dr. Nolan’s paper
were discussed and generally approved of. It was finally proposed by Dr.
Donelan, seconded by Dr. Gavin and passed unanimously:

“ That the Parliamentary Sub-Committee of the Irish Division be directed to
consider matters relating to the central control of the asylum service and any
cognate matters, and to furnish a report to the Irish Division at its next meeting,
and that the names of Dr. Colies, Dr. Greene and Dr. O’Doherty be added to the
Irish Division’s Parliamentary Sub-Committee.”

The Hon. Secretary mentioned that Dr. Eustace kindly invited the Division to
hold its Spring Meeting at Hampstead House. Dr. Eustace’s invitation was
accepted with thanks.

NORTHERN AND MIDLAND DIVISION.

The Autumn Meeting of the Northern and Midland Division was held by the
kind invitation of Dr. A. J. Eades at the North Riding Asylum, Clifton, York, on
Thursday, October 30th, 1919.

The President, Dr. Bedford Pierce, presided.

The following fourteen members were present: Drs. G. L. Brunton, A. J.
Eades, S. Edgerley, C. L. Hopkins, G. R. Jeffrey, W. S. Kay, R. M. Ladell, H. J.
Mackenzie, H. D. MacPhail, J. Middlemass, J. E. Middlemiss, B. Pierce, J. B.
Tighe, T. S. Adair; and three visitors—Drs. H. J. Drake-Brockman, J. Lowther
and L. R. Oswald (Scottish Division).

Apologies for non-attendance were received from several members.

The minutes of the last meeting were read and confirmed.

A ballot was taken for Henry George Drake-Brockman, M.R.C.S.Eng.,
L.R.C.P.Lond., Assistant Medical Officer, the Mental Hospital, Middlesbrough.
Proposed by Drs. Geddes, Hopkins and Adair as an ordinary member of the
Association, and he was unanimously elected.

On the proposal of Dr. Eades, seconded by Dr. Middlemass, Drs. S. R. MacPhail
and Bedford Pierce and Major Street were unanimously re-elected to form the
Divisional Committee for the next twelve months.

Contribution.

Dr. G. Rutherford Jeffrey then read a paper entitled " Notes on Three
Cases, showing the Value of Hypnosis and Suggestion as an Aid to Treatment.”
The first case was that of a lady who was suffering “ presumably from mania
associated with gestation.” She broke down mentally from worry and was very
restless and exalted. She was hypersensitive, and as her condition “ was only a
passing emotional storm ” it was thought it might be checked if her mind could be
” completely calmed.” She was put under a light hypnosis and it was suggested
to her that she " would sleep all right and awaken feeling well.” She slept for
nine hours and awoke feeling much better. From this time she steadily improved
>and made a good recovery. The second case was one in which a distressing

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symptom, vim., the “ most frightful desire to injure his wife and children/’ was
made to disappear by suggestion with the aid of hypnosis. Though the patient,
who was neurasthenic and depressed, was not cured, he entirely lost the idea, and,
indeed, would hardly believe that it had ever existed. The third case was one of
neurasthenia and shell-shock in an officer who had on two occasions been
blown up and buried. He fell in love with a girl, and after behaving rudely to her
mother was told that the parents did not wish to have anything more to do with
him. This worried him and “ aggravated all his neurasthenic symptoms.” He
could not bring himself, however, to write and apologise and accept the decision.
He was put to sleep under a light hypnosis and a suggestion was made to him
that he should write. On awakening he immediately put this into effect before
attempting to do anything else. After this he certainly improved.

The first case is really one of “ marked emotionalism/’ and shows how the
patient’s mind righted itself after being put into a 11 condition of blank and calm.”
The second shows how a distressing obsession can be got rid of, and the third
indicates that a “ persistent 1 aboulia ' causing a more or less severe mental paresis ”
can be abolished by suggestion. Dr. Jeffrey says that, from his experience, he is
“ convinced that hypnosis and suggestion treatment have an important therapeutic
place in the treatment of the psycho*neuroses,” and that u given a suitable case it
is worthy of trial.”

An interesting discussion followed, in which most of the members present took
part.

Dr. Pisrce made some reference to forthcoming changes in lunacy administra¬
tion, and this was followed by a talk about the nursing examination and the effect
that the altered conditions of asylum work might have upon it.

The following resolution was then proposed by Dr. Middlemass, seconded, and
unanimously carried, that ” in the opinion of the Northern and Midland Division of the
Medico-Psychological Association the question of the revision of the Handbook
should now be considered by the Education Committee with a view to its improve¬
ment in certain parts ; at the same time this Division is of opinion that the present
standard of teaching and of the examination for the nursing certificate of the Asso¬
ciation should not be reduced.”

A very interesting and enjoyable meeting was brought to a close, a hearty vote
of thanks having been accorded to Dr. Eades for his kind hospitality.

SOUTH-WESTERN DIVISION.

The Autumn Meeting of the above Division was held at University College,
Bristol, on Friday, October 24th, 1919, at 2p.m.

The following members were present: Drs. Brown, Devine, Eager, Lavers,
Mules, MacBryan, Nelis, Soutar and Thomas, and the Hon. Divisional Secretary
(Dr. Bartlett).

Dr. Soutar was voted to the Chair.

Letters of regret for non-attendance from Drs. Aveline and MacDonald were
read.

Dr. Bartlett was nominated as Hon. Divisional Secretary.

Drs. MacBryan and Soutar were nominated Representative Members of Council.

Dr. Devine very kindly extended an invitation to the Division to meet at the
Portsmouth Mental Hospital, April 23rd, 1920.

The Chairman alluded to the loss the Association had sustained in the recent
deaths of Dr. Mercier, Dr. Drapes and Dr. Wiglesworth, which were all recorded
with deep regret by all members present.

Dr. Eager then read his paper on “ Head Injuries in Relation to the Psychoses
and the Psycho-neuroses.”

The Chairman expressed the unanimous appreciation by the audience of the able
work of Dr. Eager in this valuable record of the after-effects of head injuries.

Drs. Soutar, Devine, Lavers and Bartlett joined in the ensuing discussion.

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SCOTTISH DIVISION.

A Meeting of the Scottish Division of the Medico-Psychological Association
was held in the Royal College of Physicians, Queen Street, Edinburgh, on Friday,
November 21st, 1919.

Present : Drs. Buchanan, Clarkson, Crichlow, Fraser, Henderson, Hotchkis,
Kerr, Macdonald, T. C. Mackenzie, Tuach Mackenzie, G. D. McRae, Orr, G. M.
Robertson, Ford Robertson, Maxwell Ross, Shaw, Skeen, H. Yellowlees, and
R. B. Campbell, Divisional Secretary.

Dr. G. M. Robertson occupied the Chair.

The minutes of the last Divisional Meeting were read and approved, and the
Chairman was authorised to sign them.

The Secretary intimated apologies from Drs. D. G. Thomson, Bower, Easter-
brook, Dods Brown, Ross, Steele, Ferguson Watson.

The Business Committee was appointed, consisting of the nominated member,
the two representative Members of Council, along with Dr. G. M. Robertson, Dr.
D. K. Henderson, and the Divisional Secretary.

Drs. T. C. Mackenzie and G. Douglas McRae were nominated by the Division
for the position of Representative Members of Council, and Dr. R. B. Campbell
was nominated for the position of Divisional Secretary.

The following candidate after ballot was admitted to membership of the
Association:

lan D. Suttie, M.B., Ch.B.Glasgow, Assistant Medical Officer, Glasgow Royal
Asylum. Proposed by Drs. Oswald, Henderson, and Campbell.

The Secretary submitted a letter from the President of the Association
suggesting that the Scottish Division should nominate a representative from
Scotland to act as Chairman of the Educational Committee, and the Division
unanimously resolved that Dr. L. R. Oswald be nominated for the position. As
Dr. Oswald was not present at the meeting, it was resolved that in the event of
his not seeing his way to accept office, Dr. G. M. Robertson should be nominated
in his stead—Dr. Robertson consenting to do 50.

Dr. Ford Robertson read an interesting and very instructive paper on M The
Relation of Infections to Mental Diseases,” which was followed by a discussion, in
which several members took part.

Dr. MacDonald referred to the importance which the National Asylum
Workers’ Union had placed on the teaching and training of the Nursing Staffs of
Asylums, and he suggested that, in view of the high wages now paid nurses and
attendants, the entrance fees for the examinations for the Association’s Nursing
Certificate should be increased.

After some discussion it was unanimously resolved to instruct the Secretary to
send a Resolution from the Division to this effect to the Secretary of the
Educational Committee.

Dr. G. M. Robertson referred to the objections which the National Asylum
Workers’ Union had raised regarding the employment of female nurses in male
wards of asylums, and in view of the probability of the Union taking action in the
matter, it was unanimously resolved to draft a Memorial in support of the existing
method of employing female nurses to nurse suitable male cases, and that all
medical men interested in the treatment of mental diseases in Scotland should have
an opportunity of signing the memorial before sending it to the General Board of
Control, District Boards of Control, and Royal Asylums Boards.

A vote of thanks to the Chairman for presiding terminated the business of the
meeting.

A dinner, after the meeting, was held in Messrs. Ferguson and Forrester’s, and
was well attended.

THE LATE DR. CHARLES ARTHUR MERCIER.

Sir George Savage writes :

I feel that in some ways the characteristics of Mercier were better understood by
the general public than by the medical profession, and better by the medical press
than by our specialist journals, yet I believe it is due from us to record our
personal regard for Mercier and our regret at his death.

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Indirectly, Mercier’s name came under my notice when he was a student at the
London Hospital. My father-in-law, Dr. H. G. Sutton, whose medical clerk I
believe Mercier was, spoke of his ability, but also of his unbounded self-assertion,
for he had the audacity to go round the wards and alter some of the physician’s
prescriptions. From a student «ho would do this a good deal might be expected.

Dr. Mercier began his association with insanity by becoming Assistant Medical
Officer at Stone, The City Asylum, near Dartford, in 1882. He was there till
March, 1885. His senior was altogether unlike Mercier and their relationships
were not cordial. Mercier was the student and was not distinguished in sports or
social duties. The incompatibilities increased and Mercier gave up his post, and
in a short time arrived at consulting work. He became Resident Physician at the
Flower House, Catford, a private asylum which had belonged to the Winslow
family.

Here he was more in his element; the house and grounds were attractive and the
patients not numerous. His genial and friendly relationship with the patients gave
him his deep insight into disordered states of mind, which is such a marked
character of his writings.

He was greatly influenced by the teaching of Hughlings Jackson, who, in turn,
was the follower of Herbert Spencer. As a writer on psychological subjects he
must be compared with Maudsley, whose life work was so similar to that of
Mercier, and whose books have such a remarkable parallelism in titles and subjects
to his.

Though polished and clear, the writings of Mercier will not, in my opinion,
remain as medical classics as have those of Maudsley. Mercier had the strength
of his failings. He was a perfect bulldog in his pertinacious hold of his own
ideas, and these were not always true. Take, for example, his tiresome insistence
on the distinction between insanity and unsoundness of mind. He had for twenty
years or more an obsession that he alone had recognised this though it was more
than once made clear that this was not the fact.

He was a most prolific writer and a very able speaker. I knew him as a member
of the Casual Club, a social club where any and every subject was discussed—cer¬
tainly without any regard to the private feelings of previous speakers. The
discussions were as a rule carried on vigorously but without loss of temper.
Mercier was at his best here.

Whether later in the Journal some special articles appear on his literary labours
must rest with the Editor, but it is a task not to be readily undertaken. A rather
wild suggestion might be made that for a Maudsley lecture the parallelism
between the two be studied.

For the past few years one has looked upon Mercier as a kind of hero, for one
recognised that he knew he was fated and that nothing could stop the fatal
issue of his disease, yet with superb pluck he stuck to his work and seemed still
as briskly combative as ever. He has left a great gap in our ranks, and with
reverence we leave him.

November 28/A, 1919.

Dr. H. dr M. Alexander, Medical Superintendent, of Kingscat Mental
Hospital, Aberdeen, writes: “ In your last number of the Journal you ask for
any 4 recollections ’ of the late Dr. Mercier. He was good enough to bother
writing to me sometimes, and the enclosed extracts—though they possibly are not
what you want—are rather typical of him. Like others I have more characteristic
remarks of his, but they are personal.”

44 Relative to the absence of an index in the second edition of his text-book:

4 As to the index, let me confess that mv querulous remarks were dictated partly
by laziness and detestation of the task of making an index, and partly by
annoyance at the laziness and inefficiency of those reviewers, and they are the
majority, who form their opinion of a book from reading the preface and looking
at the index. If I must be honest and frank, I have been abominably annoyed
and have been made to waste much time by the absence of the index in that
very book.’ (June 28th, 1917.)

44 1 believe one reason my Text-book does not sell is that it is only crown 8vo
in size; students like a good pretentious-looking book, and plenty of paper for

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their money. What is printed on the paper does not much matter, so long as
there is plenty of paper.” (September 24 th t 1917.)

11 Imbecile v. Feebleminded: 'The imbecile is distinguished from the feeble¬
minded by this—that the feebleminded can, and the imbecile cannot, under
efficient supervision and control, earn enough to keep body and soul together.
When controlled and supervised his labour has this market value. The labour
of the imbecile costs as much or more in supervision and control than the product
will bring in the market.' (June 21 st, 1917.)"

SIR JAMES CRICHTON-BROWNE AND THE MAUDSLEY LECTURE
LETTER OF ACCEPTANCE.

Crindau,

Dumfries, N.B.;

August ytk t 1919.

Dear Major Worth, — I am much gratified by the invitation of the Medico-
Psychological Association which you have conveyed in such kind terms, and shall
be glad to deliver the first Maudsley Lecture in London in May, 1920.

I am keenly conscious that there are many who are much more capable than I
am of representing the most advanced stages of that movement in mental science
which Maudsley did so much to inaugurate in this country, but I have this qualifi¬
cation—and it is that no doubt that has procured me your honouring invitation—
that I was a contemporary worker with him in the field which he so intensively
cultivated from the beginning to the close of his career.

Believe me,

Yours very faithfully,

(Signed) James Crichton-Browne.

Major R. Worth, M.D., etc.

IMITATIVE SUICIDES.

In the course of a recent inquest Dr. F. J. Waldo, Coroner of the City of London,
made some interesting observations on the imitative factor in the causation of
suicides. He pointed out that, as was his custom, he had merely read in court two
or three material, relevant lines from the bulky correspondence found on the body
of the deceased. The jury and others interested in the case had had an opportunity
of perusing the documents in full. The reading of details in court lead to their
publication by the press, which not only gave pain and distress to the relatives,
but, he believed, often led to further suicides by suggestion and incitation. For
example, a short time ago three brothers, one after another, took their own lives
by placing their heads in the same stove with the gas turned on. A lessening in
the number of suicides would undoubtedly follow the suppression by the press of
detailed reports of sensational and 11 interesting ” cases of suicide. If any class of
case might advantageously be held in private by Coroner and jury to the
exclusion of the press and other members of the public, he thought it was
that of a certain number of selected cases of suicide. He did not for a moment
suggest, for instance, that cases in which the good name of an individual was at
stake should be held other than in the presence of press and public. The return
of weapons, such as pistols, knives, ropes, etc., by which suicide was accomplished,
to relatives also in some cases acted injuriously by suggestion and incitation. Dr.
Waldo added that he was a great believer generally in the usefulness of the full
publicity of the Coroner’s court, and he trusted that before long the pre-war con¬
stitutional and uniform method of sitting in all cases of inquisition with a jury
would be resumed .—Medical Officer , October 25th, 1919.

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8 l

TUBERCULOSIS AND INSANITY.

Both Increased by War Disease.

Recent reports of health officers and others call attention to the fact that tuber¬
culosis is increasing. There are various explanations, but most of the ones which
we have seen are vague and unsatisfying. At the same time, we are told from
other quarters that insanity and functional nervous disorders are on the increase
also.

So far as can be gathered, both these fears are justified by the event. The
point that arises and must be considered is whether there is any connection
between the two phenomena. Is the increase of tuberculosis due to the same
causes as the increase of insanity ? Or are the evils without relationship one to
another ?

Some time ago a writer who adheres to what, for convenience, is spoken of as
the New Medicine, ventured to prophesy that both tubercle and insanity would
increase after the war. He based his prophecy on the following considerations:

A vast number of men and women have in these last years become infected by
diseases which from their nature are very difficult to eradicate. These diseases,
which include malaria, dysentery, trench fever, the typhoids—in some cases—and
venereal diseases, act as chronic poisons. The poisons probably exert a specific
effect on the nervous system. The result is that the level of bodily expenditure on
any given effort is raised and the victim tends to fall into a state of exhaustion.

If he is not cured he remains in this state of exhaustion and exhibits marked
neurasthenic symptoms, weakness, instability, mental weariness, and soon. Bit by
bit the 11 margin of safety ” which protects from disease, whether of the body or the
mind, is worn away.

Now it seems to be the case that tubercle does not in most instances seat itself in
a healthy soil. It tends to follow other infections when the resistance of the patient
is low. It tends to ameliorate when the bodily resistance is raised against it.

Reduced Health Margin.

In the same way traits of mental instability, which may be hereditary or
acquired, do not tend, as a rule, to show themselves until some secondary factor
has reduced the margin of safety represented by health. In other words, at some
given point of weakness and exhaustion, a man, apparently mentally sound, may
uncover his predisposition and become insane. The healthy man is able by the
exercise of his will to restrain the impulse which would unseat his reason ; the sick
man is not so able. The insanities of the puerperium may betaken as illustrations
of this.

Consequently the victim of war disease—and his number is legion—is more liable
to attack than his uninfected neighbour. Tuberculosis and insanity may both assail
him with a probability of success which did not exist before he fell a victim. He
is, in a medical sense, a fortress the outer fortifications of which have fallen.

The matter is important from the point of view of pensions. In cases in which
tubercle has begun since demobilisation the victim is entitled to an inquiry into his
history during the war. If it is found that he is infected with a disease of war in
addition to his consumption—and this is by no means as rare as might be thought
—he is entitled to relief. The same thing applies in the case of insanity .—The
Times , September 8th, 1919.

CARE OF DEFECTIVES.

Estimates of ^1,660,000.

In a memorandum issued yesterday on expenditure likely to be incurred under
the Mental Deficiency ( Amendment) Bill, it is stated that it appears probable that
if full use were made of the Act during the next five years provision should be
made for the maintenance in institutions or under guardianship of about 21,700
defectives. It is estimated that the average annual cost of maintaining defectives
in institutions will be about £60 a head. The total sum required, therefore, will

LX VI. 6

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be about £ 1,300,000, with another j£i 00,000 for administrative expenses. Of
this amount half, or £700,000, will be refunded to the local authorities from the
Exchequer. The whole of this sum will not be required at once, but may reach
the estimated figure in about five years’ time. It is estimated that in Scotland
provision should be made for the maintenance of about 4,000 defectives, and the
cost of these at £60 a head and other items is expected to aggregate about
^260,000, of which half will be repayable from the Exchequer.— The Times ,
November 27th, 1919.

APPOINTMENT.

Stken, Robert Hunter, M.D., M.R.C.P.Lond., Out-patient Physician for
Psychological Medicine, King’s College Hospital, Denmark Hill, London.

ERRATUM.

The 67th Annual Report of the Inspectors of Lunatics (Ireland) for 19x7 : A
correction. —Page 264, line 47, the reviewer has made an error in the column of
the table referred to. The figures quoted refer to deaths; 8 8 per cent, is the
percentage of deaths on the daily average.— Eds.

NOTICE TO CONTRIBUTORS.

N.B .—The Editors will be glad to receive contributions of interest, clinical
records, etc., from any members who can find time to write (whether these have
been read at meetings or not) for publication in the Journal. They will also feel
obliged if contributors will send in their papers at as early a date in each quarter
as possible.

Writers are requested kindly to bear in mind that, according to Lix(a) of the
Articles of Association, u all papers read at the Annual, General, or Divisional
Meetings of the Association shall be the property of the Association, unless the
author shall have previously obtained the written consent of the Editors to the
contrary.”

Papers read at Association Meetings should , therefore , not he published in other
Journals without such sanction having been previously granted .

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JOURNAL OF MENTAL SCIENCE, APRIL,

920.

Thomas Drapes, M B.Dub!., L.R.C.S.I.

Obiit October 5th, 1919. President-Elect 1910-11.

Co-Editor of Journal since 1912.

Adlard 87 Son 87 West Newman, Ltd.

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THOMAS DRAPES,

[April,

he was able to marry io 1875, his wife being a member of an old
Enniscorthy family, the Prestons of Salville. In 1883, however, the
position of Resident Medical Superintendent of Enniscorthy Asylum fell
vacant on the death of Dr. Joseph Edmundson, and Dr. Drapes,
deciding to become a candidate, was elected on September 4th
of that year. Thenceforward until his resignation last May he managed
the affairs of that important institution with a success to which those
connected with its administration have borne testimony. As in most
asylums at that period, the accommodation and equipment of the
Enniscorthy institution left a good deal to be desired, and Dr. Drapes
speedily induced the managing body to initiate a series of improvements,
as the result of which the buildings were enlarged by the addition of two
new wings, a laundry, and a kitchen, while the interior of the older part
was remodelled and improved. As time went on other matters received
attention. A new system of drainage was installed, as well as a new
water supply and a general heating plant, while in comparatively recent
times wise advantage was taken of an opportunity of purchasing a
derelict mill, which rendered it possible to supply the asylum with
electricity for lighting and power purposes at a very economical rate.
Although the structural improvements effected during Dr. Drapes’ period
of office involved considerable expenditure, there is no doubt as to their
wisdom and necessity, and it has been well stated that the manner in
which they were carried out "will long remain a monument to his
prudence, foresight, and remarkable business capacity.” Meanwhile
the training of the staff in the proper care of the insane was not
neglected, while in his dealings with the members he always showed
not only a desire to secure efficient performance of duty, but also
a kindly solicitousness for their welfare which rendered the relations
between them of a peculiarly friendly character. This was acknow¬
ledged on his departure from the asylum by a valuable presentation;
and when the sad news of his death came, it may safely be said that,
outside his family and personal friends, no more sincere regret was felt
than amongst those who had been his subordinates.

Rut structure and administration are but means to an end, and,
though successful in these directions, Dr. Drapes was always first and
foremost a physician; and it was in his personal and professional
relations with the afflicted beings who passed through his hands that
the bent of his mind and character were most conspicuously shown,
while the unfailing kindliness and conscientious care which characterised
his attitude to his patients were no more conspicuous than the keen
medical and scientific interest which marked his observation and
treatment of the forms of disease from which they were suffering.

On his appointment as Resident Medical Superintendent he joined
the Medico-Psychological Association, and it is not too much to say

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1920.]

that bis intimate connection with that society, which brought him into
touch, not only with the alienists of Ireland, but also with the leading
members of the specialty in Great Britain, afforded him some of the
happiest moments of his life, while providing opportunities for the
expression and discussion of his views which were advantageous both
to himself and his fellow-members. In his first paper read before the
Association he dwelt on the difficulties which beset the medical officer
of a country asylum who desires to keep abreast of the progress of
science and so to do his best for his patients; and there can be no
doubt that it was his constant effort to carry out in practice the very
practical suggestions which were there made for overcoming them.
During his whole career he continued an active member, contributing
to the Journal of the Association a series of valuable papers on the
statistical, clinical, and other aspects of bis subject, which were marked
by careful observation, clear reasoning, and lucidity of expression, as
well as other useful work in the form of reviews; while at the various
gatherings of the society his genial presence, no less than his alertness
of intellect and ready power of fluent speech, made him a welcome
figure. It was therefore natural that the Association should eventually
mark their appreciation of him and his work by choosing him for the
highest office in their gift, that of President, which he should have held
during the session 1911-12. Unfortunately bis health in the spring
of 1911 gave so much anxiety that he felt obliged to withdraw, but he
was able to attend the annual meeting at Dublin in July, 1911, and
contributed to its success by reading an excellent paper on “The
Personal Equation in Alienism.” In the following year (1912) it was
felt that fuller advantage should be taken of his literary ability, and he
was unanimously elected Co-Editor of the Journal of Mental Science —a
choice which was more than justified in the years that followed. Up to
midsummer, 1915, his editorial duties were mainly routine, except for
one or two occasional articles; but at that time the Senior Editor,
Dr. Lord, having taken a commission, was obliged to relinquish work
on the Journal owing to his military duties, and thenceforward until the
end of the war Dr. Drapes had sole responsible charge, though well
supported by the Assistant Editors. Both his mental endowments and
his training peculiarly fitted him for such work, for with accuracy,
punctuality, and conscientiousness he combined a thorough knowledge
of English and a sound working acquaintance with French and German,
while his keenness and quickness of intellect roust have rendered
editorial routine easier for him than it would have been for many.

In his views on the disputed questions of psychology Dr. Drapes’
tendency was in the direction of conservatism, and in addition he was
too clear and honest a thinker to accept without question new opinions,
no matter how eminent the authority by whom they were advanced.

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[April,

Thus he never could bring himself to adopt the doctrines of Kraepelin,
to many of which he was in outspoken opposition, and his attitude to
psycho-analysis may probably be accurately judged from a statement
in the prefatory note to his translation of Delage’s Une Psychose
Nouvellt (published in the Journal of Mental Science of January, 1917),
to the effect that Freudism “ in the view of many sober thinkers is, in
much of its theory, scientifically unsound, and at least capable of
becoming demoralising in practice.” With the philosophic position
of Maudsley, however, he was to a great extent in sympathy, his desire
for orderly system and definiteness of thought inclining him, as it did
many able men of his period, in the direction of a materialistic conception
of mind. He was not, however, disposed to go as far as his leader,
and he found it possible to reconcile a material attitude towards
scientific truth with adhesion to the essential doctrines of Christianity,
if we may judge from the fact that he took an active interest in the
work of the Church of Ireland in the parish and diocese in which he
lived.

For the various spheres of activity to which allusion has been made
by no means exhausted the interests of his many-sided mind. Thus he
served on the Synod of his diocese, as well as holding other Church
offices, and he took a particular interest in temperance work; while his
love for music—he was at one time a good pianist—led him to act for
thirty years as secretary of the local Choral Union, the members of
which marked their gratitude to him by a handsome presentation on his
leaving the district. He was also no mean photographer, was interested
in chess, and was a keen croquet player and an occasional golfer ; and
he took his part in all the social life of the neighbourhood, his geniality
and sense of humour making him a most pleasant companion and
winning him numbers of friends, to whom his loss has brought unfeigned
sorrow.

Although, beyond some degree of deafness, the passing years seemed
to have little effect upon him, there can. be no doubt that a certain
fatigue was making itself felt, which was probably accentuated by the
multitudinous anxieties and occupations of the last five years, and lately
by the spread of the general industrial unrest to the staffs of asylums,
though happily at Enniscorthy tact and good feeling rendered it
possible to avoid a strike, such as unfortunately occurred in some
other institutions ; and when, with the approach of the County Council
elections, it became evident that the new Asylum Committee would
differ in many respects from that under which he had worked on such
friendly terms for so many years, he decided that the time had come
for him to give place to a younger man, and he severed his long
connection with Enniscorthy Asylum on May 15th, 1919.

Great as the wrench must have been in leaving the place with which

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BY W. R. DAWSON.

1920.]

he had been assoc ated for nearly half a century, the rest and relief
from responsibility gradually produced their effects, and even shortly
before his death it was noticed how well he was looking. His new
house and its arrangements provided him with pleasant interests, and his
connection with the Medico-Psychological Association and its Journal
kept him in touch with lunacy matters, and enabled him still to do
useful work in the cause of the mentally afflicted. At the annual meeting
of the Association at York in July, 1919, he was his old cheerful self,
and his many friends there little thought that they had seen him for the
last time.

All went well until the death of his brother-in-law rendered it
necessary for him to return to Enniscorthy at the end of last September,
and on the journey he contracted a chill which after his return home
developed into double pneumonia, and brought his life to a close on
Sunday, October 5th, 1919. His widow, a daughter and four sons
remain to mourn his loss. Their grief has been shared, not only by
his close personal friends, but by the committee of his asylum,
his subordinates on the staff, and all, it is not too much to say, with
whom his varying activities brought him in intimate contact.

Dr. Drapes, as has been said, succeeded as an administrator, but he
was first and foremost a physician, and amid so many calls upon his
time he never failed to keep up with the advance of knowledge, not
only in his own subject, but in general medicine. Had his lot lain
elsewhere, the quickness and lucidity of his intellect and his ready
power of expression with voice and pen would have rendered him an
admirable teacher, and there is little doubt that he would have taken a
position at least more conspicuous in the world’s eyes than that which
he was called to fill; but it may well be doubted whether such a
position would have given him greater happiness in his life, while it
could not have increased the respect and affection in which he was
held. An upright and honourable gentleman, as free as a man may be
from self-seeking and self-assertion, quiet and unassuming in manner
despite his knowledge and attainments, cheerful, humorous, hopeful,
ready to do what he could for all, he was, as has been well said,
“ one of the kindest, straightest, and most loyal friends a man could
ever have,” and he leaves a memory which any might envy.

W. R. Dawson.

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IDENTITY OF THE PSYCHOSES AND NEUROSES, [April,

Part I.—Original Articles.

The Identity of the Psychoses and the Neuroses. By John
Macpherson, C.B., M.D., F.R.C.P.Edin, Commissioner of the
Board of Control for Scotland.

Half a century ago Maudsley wrote (*) “ A pregnant but very difficult
question of which little or no thought has ever been taken by writers on
insanity is—What is the cause of the particular form which the disorder
takes in a given case? Why does it assume one complexion rather
than another? At the outset it is certain that what appears to be
the same cause shall occasion different forms of insanity in different
persons and even in the same person at different periods of life, and
that the same form of disorder shall be produced by different causes;
this being so it is plain that the special determining conditions lie
hidden in that unknown region which we call by such names as
‘ temperament * and ‘ idiosyncrasy.’ ”

If these questions, which have all these years remained unanswered,
have not been brought nearer a solution by the medical lessons of the war,
the scope of their inquiry has at any rate been broadened. We have
learnt that a uniform group of powerful emotions, coupled in a certain
proportion of cases with unusual strain, can be the exciting cause of the
appearance of the symptoms of both the neuroses and psychoses;
that no new forms of the neuroses or psychoses have been produced as
a result of the war; that war neuroses and psychoses depend in the
majority of cases upon an inborn temperamental neurotic disposition—
in other words that they were not caused, but revealed or accelerated by
war conditions; that neurasthenia and the so-called psycho-neuroses
may pass into definite forms of the psychoses; that the mode of origin,
course and termination of the war neuroses and psychoses are in the
main similar; and that the majority of cases of war psychoses have been
successfully treated and tended towards recovery without recourse to the
legal formalities established for the protection of the sane and the insane.

Twenty-five years ago my respected teacher, the late Sir Thomas
Clouston, assumed the identity of the psychoses and the neuroses in his
Morison lectures entitled “The Neuroses of Development.” The scope
of these lectures embraced epilepsy, hysteria, and his own adolescent
insanity—later on differentiated by Kraepelin into mania-melancholia
and dementia precox.

Clouston emphasised the relationship of the psychoses and neuroses,
mainly on the ground of their developmental origin, and did not push
the analogy further. Had his creative mind been earlier directed
to the consideration of the subject he might probably have enunciated
more far-reaching conclusions. To him, however, belongs the.merit of
having first proclaimed this identity.

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BY JOHN MACPHERSON, C.B.

Ten years later I bad the privilege of delivering the Morison Lectures
and chose as their title “ Variation in Relation to the Origin of Insanity
and the Allied Neuroses." The thesis proved sufficient so far as mental
defect and the neuroses were concerned, but when the point was
reached of applying it to the insanities my vision of the problem failed
me. This failure, I now see, was due to the prevailing conception
of the term "disease” as applied to the insanities—a conception which
has never been called in question, although unconsciously we differ*
entiate its use when we think of different forms of insanity. That is to
say, while we apply the term “ disease ” in an equivalent sense to acute
mania and typhoid fever, we either do not apply it or apply it in a
different sense when we refer to congenital mental defect

In the ordinary work of our specialty we see, as a rule, only the more
pronounced and advanced forms of mental disorder, which we designate
" mental disease.” The designation is justifiable in a medical sense so
far as concerns the profound mental and bodily disturbances which
accompany the acute psychoses; but there are milder forms of the
psychoses which never reach mental hospitals and whose symptoms do
not, as a rule, suggest to the lay mind the existence of mental disorder.
The concentration upon one—the more severe—group has certain dis¬
advantages : it prevents a comprehensive and comparative view of the
whole field of morbid psychology; it tends to the setting up of an arti¬
ficial barrier, inside which are the mentally "diseased” with their
physicians and attendants, and outside of it the subjects of the unrecog¬
nised psychoses, the medical profession, detached and uninterested, and
the general public, who manifest an instinctive dislike to everything
labelled “ insanity.” The remedy for this state of matters is the educa¬
tion of the medical profession; but the educators are on one side of the
barrier, and they must as a first step come over and investigate the forms of
mental disorder which undoubtedly exist in the outer world. It is true
that such accomplished authorities as Morel, Pritchard and Maudsley
—to name three out of several—did recognise this outer field of morbid
psychology, but except that they mention mental depression and hallu¬
cinations they refer to its other manifestations vaguely as eccentricity,
immorality, vice, and even genius.

In order to appreciate the extent to which unrecognised mental
disorder exists in the general population one must possess psychiatric
experience and have the opportunity and desire to observe. Given
these conditions it should be possible to detect, almost anywhere,
mental defect, intellectual or moral; the various forms of mild dementia
praecox or the terminal stages of that disorder; the periodic emotional
oscillations or the recurrence of mild depression or mild exaltation
which characterise manic-depressive insanity; or the unfounded sus¬
picions, the delusions, the aggressiveness and the vindictiveness which

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indicate paranoia. The aberrations of conduct which accompany these
mental disorders are usuallyattributed to moral rather than to pathological
causes. For instance, alcoholic and sexUal irregularities are commonly
associated with the exalted phase of the manic-depressive syndrome; in
the depressed or lucid intervals of the disorder the same subjects may
be models of good behaviour. If, however, the pathological condition is
not recognised, misconduct falls to be explained on other grounds. The
aimlessness, the inefficiency and idle habits in the milder forms of
dementia praecox, the incompetence or immorality in mental defect
and the unreasoning aggressiveness in paranoia are all unrecognised
and misinterpreted.

The milder forms insensibly merge, by gradation, into the pronounced
forms, so that at one end of the scale we see conditions unattended by
physical disability, and such a slight degree of mental disturbance that
it escapes recognition and is usually interpreted in terms of moral
conduct, and at the other end conditions which pass into definite
disease in the ordinary medical acceptation of the term.

It is precisely the same with the functional neuroses. Epilepsy and
hysteria may become veritable diseases in the medical sense, yet on the
other hand they frequently reveal themselves as mere episodes in the
useful lives of countless individuals in every generation and every race of
mankind. As in the case of the psychoses the milder forms pass by
gradation into the severer forms which attain to the status of disease.

But neither in the psychoses nor in the neuroses is the “ disease ”
form typical of either group; the clinical aspect of both can be better
appreciated by treating their natural history together. Thus:

(1) They are all markedly hereditary.

(2) The heredity is transformable-—neuroses appearing in the ante¬
cedents and collaterals of the subjects of the psychoses and vice versA —
from which we may imply the existence of a common hereditary basis.

(3) They constitute genetic variations from the normal in respect of
a hyper-excitability of the sensori-motor elements of the cerebral cortex,
which renders the subjects susceptible to mental suggestion or to
physical or mental impressions which do not similarly affect normally
stable individuals.

(4) There is present in the majority of the subjects a perceptible
psychical modification more marked during the episodic crises, and which
tends sooner or later towards a varying degree of mental deterioration.

(5) The symptoms exhibit a marked tendency to periodicity,
irregular recurrence, exacerbation, or relapse.

( 6 ) As a rule this tendency to periodicity and recurrence continues
throughout life, but it may weaken in maturer life as the vital and sexual
forces subside.

(7) No anatomical lesion or defect of the nervous system has been

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observed upon which a pathology of the functional neuroses or the pure
psychoses can be established.

(8) There is present, at any rate in the severer forms, which alone
have been investigated, certain disturbances of metabolism, of the
blood elements and of the vaso-motor functions, of the causes and
nature of which we are ignorant.

(9) The symptoms usually commence to manifest themselves in early
life—childhood and the adolescent period.

(10) The neuroses and psychoses have no geographical or racial limit
but affect individuals of all human races, and, so far as that is possible,
of several of the higher animal species.

The first six points are so generally admitted that comment is
unnecessary; the last four require further explanation.

If there is no anatomical change in the structure of nerve tissue
characteristic of all phases—mild or severe—of the neuroses and
psychoses, then we have to deal with functional and not organic
disorders.

The published descriptions of secondary or degenerative changes in
the nervous system following upon long-continued recurrent crises or
severe attacks of the characteristic manifestations of the neuroses or
psychoses do not establish a pathology. Neither do the striking
changes in nerve-cells, especially in the acute psychoses, which are
occasionally described, but which more probably result from intercurrent
super-imposed auto-intoxications, carry us any nearer a solution. The
fact remains that in a comparatively large proportion of cases, even
when the crises are frequent and extend over long periods of years,
there have not been discovered such uniform anatomical changes as
would justify a pathology founded upon the morbid anatomy of the
nervous system. This negative evidence does not, however, exclude
the possibility of undetected changes. It might be argued that as the
psychoses and neuroses are hereditary variations their solidarity with
mental defect is more than theoretical. We know that in lower-grade
defectives physical malformations—the outward signs of nervous mal¬
formations—are numerous, and that these malformations become fewer
in the ascending scale of defectives until they finally disappear alto¬
gether in the highest class, in which the only remaining diagnostic
criteria are what we vaguely term mental instability and a tendency to
suffer from one or other of the neuroses or psychoses. We also know
that the nerve-cells of epileptic idiots show certain characteristic
changes, and that in lower grades of mental deficiency certain layers of
cortical cells are less developed than in normal subjects. It is not,
therefore, illegitimate to assume that these, and probably other changes,
extend in a modified degree to the hereditary subjects of the neuroses
and psychoses. Again, we know that in Jacksonian epilepsy certain

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limited groups of cortical cells may acquire an explosive quality, but it
has never been asserted that these cells—which have often been excised
with good results and examined carefully after excision—have exhibited
any perceptible difference from normal cells. Quite recently Sir
Frederick Mott(*) has shown us the changes in certain glands—especially
the testicles—in dementia prsecox, and has correlated these with
degenerative changes in the nuclei of the cortical neurons. We await
further information from his indefatigable and illuminating researches.

Whether or not the metabolic disorders which undoubtedly accom¬
pany the severer crises of the psychoses and some of the neuroses are a
constant feature of all phases—mild or severe—of the various groups, or
whether that disorder is primary or secondary, is for the present uncertain.

It is unfortunate that the researches of Dr. Lewis Bruce have
not been followed up. His writings remain our sole guide on this
interesting and important subject. He found that in the acute
phases of dementia prsecox and manic-depressive insanity there was
hyper-leucocytosis with an increase of polymorphonuclear cells. A
relapse was generally preceded by a fall in the leucocytosis; when a
case recovered the leucocytosis remained high for months and even
years; in cases which became chronic or demented the leucocytosis
and the percentage of polymorphonuclear cells fell. Bruce also found
hyper-leucocytosis present in epilepsy, not only during the period of
the seizures but in the intervals between them. Coincident with the
hyper-leucocytosis there was generally a high blood-pressure.

Bruce attributes these phenomena to toxaemia but does not suggest
any special toxin. In some undoubtedly infectious diseases, such as
phthisis and typhoid fever, there is pyrexia without leucocytosis; in the
present instances we see leucocytosis with nar-or very slight—pyrexia.
The relation of nervous perturbation to metabolism has yet to be
discovered, but the features mentioned seem to point to secondary
changes the result of some direct disturbance of the nervous mechanism
affecting the secretion of the endocrine glands. In any case it seems
probable that the intoxication is not specific, that it varies in intensity
with the severity of the nervous perturbation, and that its deteriorating
influence on the finer structure of the cortex depends upon the nature of
the toxins, the age of the individual and the resistance of the body tissues.

Although there is no age at which the manifestations of the
characteristic. symptoms of the psychoses and the neuroses may not
appear for the first time, the following figures show that in a pre¬
ponderance of all cases they occur before twenty-five years of age:

Epilepsy (Gowers)....

0-85.

. 89‘6 percent.

Hysteria „ .

• 7 *° ..

Mania-melancholia (Kraepelin)

6 o‘o „

Dementia praecox „

66 ‘o „

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BY JOHN MACPHERSON, C.B.

With regard to the psychoses, Thumam (Statistics of Insanity) and
Ktaepelin {Psychiatric) agree that the stated age of the development of
the symptoms is misleading, and that probably a much larger proportion
of the cases should be placed in the earlier period of life (before
twenty-five) than is at present done. The age on admission to hospital
is usually correct, but the duration of the illness prior to admission as
well as the existence of previous symptoms is open to obvious error.

During much the greater part of last century the opinion prevailed
that the neuroses and especially the psychoses were diseases, if not
directly the result of civilisation, at any rate and in some vague manner
augmented and intensified by it. At present a different opinion—that
they are genetic variations—is beginning to find favour, but our faces still
continue to be oriented towards the older view. The following facts,
though not in themselves conclusive, may help towards a decision
between these two views; for it is only reasonable to suppose that dis¬
orders which are a common inheritance of humanity and of some of the
higher animals are neither the phenomena of acquired disease nor the
results of civilisation.

Epilepsy in all its forms is met with in domestic animals, including
fowls and birds. Friedenberger and Frohner ( s ) divide the disease as it
occurs in domestic animals into idiopathic, symptomatic, traumatic and
reflex epilepsy. They also describe the minor form (petit maJ).
“ During the periods between the fits,” they say, “ the animals show all
symptoms of health; mental depression, cerebral troubles, dulness of
the senses and of the intelligence are rare.”

“Of all the diseases included in the group of the neuroses,” says
Hirsch (*), “ none shows a prevalence so general in time and place as
epilepsy; none is so constantly present in the morbid life of humanity;
none has so markedly the ubiquitous character.” Epilepsy would
appear to be uninfluenced by climate or soil or race or habits of life.
It is of the same type and generally common in all the races of Europe,
in the Moorish population of Algiers, among the Mongols of Northern
and Southern Asia, among Malays, Javanese, natives of Peru and
Indians of Brazil. In fact, so far as is known, no race in the world is
exempt. Local differences undoubtedly exist in the prevalence of the
disease. These are best obtained from the records of countries which
have military conscription. In France the number of conscripts sent
back on account of epilepsy, from 1831 to 1853, was 6,627 in a total of
4,036,372, or 1*6 per 1,000; but taking the period 1850 to 1869 it rises
to 275 per 1,000. In Italy, out of 2,333,288 recruits medically inspected
in fifteen years, 5,103, or 2’4 per 1,000, were rejected on account of
epilepsy. In Belgium the proportion was 0*90, and in five districts of
Wurtemberg 0*93. In the several provinces of France the proportion
of epilepsy appears to vary irregularly from o - 5 to 3'4 per 1,000. In

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Italy the distribution shows as a general rule that the disease pre¬
dominates in the Southern and Western provinces in contrast to the
North-Eastern.

From these and other sources Hirsch estimates the average frequency
of the disease in Central and Southern Europe at about 1*5 per 1,000
inhabitants.

Catalepsy, which in the human subject is frequently an associated
symptom of hysteria, is common in animals. It has been recognised in
the ox, the dog, the horse and the prairie wolf. According to Frieden-
berger and Frohner the symptoms which are analogous to hysteria in
man usually commence suddenly without any precursory indications; in
some cases, however, there is anxiety, excitement or loss of appetite.
The animals are unable to make the slightest voluntary movement;
they remain immobile in the position in which the catalepsy has
surprised them. Muscular resistance and rigidity are at first apparent
but these symptoms gradually pass off. Intelligence is more or less
affected and general sensitiveness is greatly diminished. The attacks
may be repeated and their duration is uncertain, lasting from a few
minutes to a few hours. A peculiar form of balking in horses is
described by Friedenberger and Frohner which may culminate in
veritable mania and is accompanied by serious cerebral symptoms.
This phase of excitement is succeeded by a considerable depression of
strength. Hysteria in the dog may assume extreme forms, and
instances are recorded in which hysterical paresis occurred.

The symptoms of hysteria among primitive peoples are so inextricably
conjoined with alleged demoniacal possession, gifts of prophecy,
religious ceremonies and the practice of the healing art that it is not
always possible to dissociate them.

Tylor ( 5 ) remarks: “ Persons whose constitutional unsoundness in¬
duces morbid manifestations are indeed marked out by nature to
become seers and sorcerers. Among the Patagonians patients seized
with falling sickness or St. Vitus’ dance are at once selected for
magicians and soothsayers. Among Siberian tribes the Shamans select
children liable to convulsions as suitable to be brought up to become
hereditary members of the Cult.”

Estimated by its universal diffusion over the world, hysteria must be
the most common of all the neuroses. In the very oldest Brahminical
writings, which precede by thousands of years the Christian era,
mention is made of it among the diseases of the nervous system.(*)
Coming down to modern times, we find it constantly referred to in the
writings of travellers. Judging from the comparative frequency of these
references, we can form the opinion that one of the principal seats of
the malady is the group of countries in the arctic latitudes of the Eastern
Hemisphere, including Iceland, the Faroe Islands, Lapland, and the

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1920 .]

parts of Europe and Asiatic Russia in the extreme north. From these
regions we have information of the truly endemic prevalence of hysteria
among the women of the Samoyeds, of the Yakuts, and other Siberian
tribes, as well as among the inhabitants of Kamtschatka. It is also
unusually common among the women of Samara and the Kirghiz Steppes.
Although hysteria is common enough in Central Europe, it is less so
than in the northern or the southern parts of the Continent, such as the
south of Spain or Italy. Oppenheim, quoted by Hirsch, states that in
Turkey it is “ the heritage of women and the scourge of men."( T ) Dr.
Roser, quoted by Hirsch,( 8 ) states that in Gnadenthal in South Africa
there are few Hottentot women living there who do not suffer from
hysteria in one form or another. The same appears to be true for the
Abyssinian territory bordering on the Red Sea, for parts of Egypt and
for Tunis. On the table-land of Mexico hysteria counts among the
commonest of diseases, and it is frequent in Costa Rica, Brazil, Chili
and Peru. Among the inhabitants of the Malay Peninsula a peculiar
manifestation of the disease, known as “ latah,” is very common. Dr.
Ellis gives an excellent description of it.( 9 ) “ The symptoms in a latah
subject can be suddenly aroused in many different ways, usually trivial
in their nature, such as an unexpected noise, some sudden action on the
part of a bystander, a sudden touch, or the mere mention of some
word—usually the name of a wild animal, such as a tiger. The duration
of the phenomena is variable, and may last from a few moments to half
an hour or more.” Latah is as old as the known history of the Malays.
The sufferers are more frequently females than males, and, though
there are differences of opinion on the point, it is generally held to be
more common among young females. The disease is nearly always
hereditary.

When we turn from endemic to epidemic hysteria we open out an
endless field which is quite beyond the scope of this paper. One refer¬
ence, however, must be made in order to complete the subject. In
Madagascar, in the year 1864, a peculiar epidemic of hysteria occurred
among girls and young married women from fifteen to twenty-five
years of age. The occasion of the outbreak, which began at one point
and spread gradually almost over the whole island, was the profound
sensation caused among the people by the violent death of the king
and the consequent changes in the religion and laws. The morbid
phenomena were almost identical with those of the dancing mania of
the Middle Ages.( 10 )

When we come to inquire into the similar prevalence of insanity the
evidence is much more negative, and although there is no race of men
who are known to be free from it, yet on the whole travellers are in too
many instances silent It is evident either that the subject does not
interest them or they simply say that they saw no insane people. Hence

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has arisen the mistaken idea that insanity is a product of civilisation,
and that it is rare or unknown among savage or barbarous people. I
collected on another occasion numerous references from the writings of
travellers for the purpose of showing the unfounded nature of the belief
which has arisen on this subject. Dr. Felkin informed me that he had
seen in all some thirty or forty lunatics on the White Nile. He also
saw some maniacs chained. He was the first to tell me a fact, of which
I have since had confirmation from other sources, namely, that the type
of insanity among the African natives is different from that in Europe.
The prevailing form of mania is a short acute kind, lasting only a day
or two, during which the sufferer is driven away to the woods, or volun¬
tarily runs away, returning again in a few days apparently restored in
mind. Idiocy was very common in his experience, and so was suicide.
Thomson, in his book, Through Masailand, states that he found
insanity very common. The myths and folk stories of the people are
full of reference to it. Those affected by lunacy are driven away from
the habitations of sane people, or are otherwise isolated. He also
found idiocy very common, especially among the dwarfs and albinos,
the latter of whom were numerous, and about the prevalence of mental
defect among them there was no doubt. Captain Cook, in his Voyages ,
referring to the South Sea Islanders, says: “ We met with two instances
of persons of disordered mind, the one a manat Owhyhee, and the other
a woman at Oneheeow. It appeared from the particular attention and
respect paid to them that the opinion of their being inspired by the
Divinity, which obtains among most of the nations of the East, is also
received here ” (in the Pacific). ( 1J )

Ellis, in Polynesian Researches , says: " Insanity prevailed to a slight
degree, but individuals under the influence met with a very different
kind of treatment. They were supposed to be inspired or possessed
by some god, whom the natives imagined had entered everyone suffer¬
ing under mental abberration. On this account no control was exer¬
cised, but they were treated with the highest respect. They were,
however, avoided," etc.

Emin Pasha, in his book, Central Africa , says: “ Insanity and also
temporary mental aberration are frequent. The latter is treated with
herbal remedies, which effect an immediate cure by means of sleep and
sweating.” f 1 *) Wilson and Felkin state: “ Temporary madness is pretty
common, and generally lasts for three or four days, but persons thus
afflicted do not become very violent.” ( 1S ) I might go on indefinitely
multiplying extracts from the writings of travellers to the same effect, but
it would serve no additional purpose.

There is another reason why this belief in the immunity of the less
civilised from insanity has obtained currency, and it is because no
qualified person has been at the trouble to investigate the matter.

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About sixteen years ago, however, Prof. Kraepelin, of Munich, went to
Java and analysed the forms of insanity among the natives in one of
the large asylums there.( 14 ) His first inquiry was whether the influence
of climate and other tropical conditions of life modified in any way
the symptoms of mental disease. He found that Europeans bom and
reared in Java present exactly the same clinical types of mental
diseases as at home. As to the abuse of stimulants and narcotics,
the natives do not drink alcohol, and there were therefore no cases of
alcoholic insanity among the native population of the asylum. Opium
smoking and abuse of the drug is, however, common, yet no patients
in the asylum owed their insanity to that cause. The same is true of
the large asylum at Singapore, in which city the Chinese population is
notoriously given to the abuse of the drug. Of especial interest also is
the fact that out of 370 insane natives there was not a single case of
general paralysis, whilst among fifty European men who were inmates
of the asylum at the same time there were eight cases. Dementia
praecox was found to be extremely frequent, and, on the whole,
presented similar symptoms to those found among Europeans. On
the other hand, mania-melancholia was rare. Many cases seemed to
bear a resemblance to it, but they were found, on closer observation,
to be distinct and peculiar forms of epileptic or hysterical mania. In
those cases in which there was no doubt in diagnosis, the symptoms
presented several variations from the European type. Especially was
this the case in the depressed form of the mania-melancholia syndrome,
where many of the characteristic symptoms were wholly absent. For
instance, ideas of "sinning” were never expressed, and maniacal
agitation was less developed, and more monotonous, than is usual in
western Europe. The great difficulty experienced in forming a satis¬
factory diagnosis of mental affections in Java was the preponderating
amount of “ amok ” and “ latah ” among the patients. The symptoms
of these semi-hysterical diseases not only formed special clinical groups,
but they appeared also to colour the character of other and distinct
forms of insanity. Latah is the great mental affection of the Malays,
just as hysteria is the corresponding disease par excellence of the
Samoyeds and Kamschatkans and other nations of north-eastem
Europe and northern Asia. Short, quickly-passing hystero-maniacal
attacks, similar to those which Emin Pasha and Felkin describe among
the natives of the Soudan, Kraepelin describes as frequent among the
Malays. This leads to the conclusion that it is not so much a question
of the frequency of insanity as of its type which ought to be the basis
of inquiry when studying its manifestations among peoples widely
separated in development, whether racial or social.

Upon some such basis as the foregoing must rest, for the present,
the argument in favour of regarding the psychoses and neuroses as one

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group. The practical results of the acceptance of the proposition
which I have endeavoured, perhaps too academically, to formulate may
be shortly stated.

The psychical element which underlies, often causes and generally
accompanies the symptoms of the functional neuroses justifies their
inclusion within the domain of psychiatry. The influence of their
inclusion would profoundly modify the present too limited sphere of
psychiatry in this country.

The acceptance of the view of the identity of the psychoses and
neuroses would imply the belief that they share in common an inborn
constitutional defect which is ineradicable and irremediable, of which
the varying crises and the tendency to periodicity and recurrence are
the phenomena. The recognition of this fact would constitute an
advance towards a sounder appreciation of the problem of the nature
of the psychoses. It should also lead to a more comprehensive view of
the whole field of morbid psychology.

The war has demonstrated, what Maudsley long ago indicated, that
one and the same cause may originate in neuropathic persons any of
the various forms of the psychoses or neuroses, depending upon the
particular temperament or idiosyncrasy of the individual Inimical
causes continue to act in so-called times of peace as in times of war,
with the result that there exists in the general population a mass of
definite and indefinite neurosis and psychosis which is at present
unstudied and disregarded.

An obvious corollary to the views that the neuroses and psychoses
are fundamentally one, and that the psychoses extend far beyond the
limits of legal certification, would be a recognition of the necessity for
the establishment of psychiatric clinics in connection with all medical
schools and in all important populous centres for the relief of suffering,
for the preventive treatment of the neuroses and psychoses, and for the
education of the medical profession in the clinical features of medical
psychology.

A responsibility for the initiation of a propaganda for the formation
of these clinics and for the many other reforms which must follow
upon their establishment is incumbent upon all psychiatrists who have
come to a consciousness of the deficiencies of the present system, and
upon those neurologists who have rendered such]valuable service during
the war in the treatment not only of the neuroses but of the psychoses.

(*) Pathology of Mind, p. 236.— ■(*) Brit. Med. Journ., November, 1919.—
(*) Pathology and Therapeutics of Domestic Animals .—( 4 ) Geographical and
Historical Pathology .—(*) Primitive Culture, ii, p. 132. —(•) Wise Commentary on
Hindu System of Medicine, p. 250.— (*) Geographical and Historical Pathology ,
vol. iii, p. 519.—(®) Loc. cit., p. 521.— (®) Joum. Ment. Sci., London, 1897, p. 33.
—(*°) Hirsch, loc. cit., p. 529. —( u ) Cook's Voyages, vol. iii, p. 131. —(**) Central
Africa, p. 94. —(**) Uganda and Egyptian Soudan. —( 14 ) Centralbl. f. Nervenh
Leipzig, July, 1904.

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CHRONIC HALLUCINATORY PSYCHOSIS.

Chronic Hallucinatory Psychosis. ( l ) Robert Hunter Steen,

M.D.Lond., M R.C.P.Lond., Medical Superintendent, City of
London Mental Hospital, Professor of Psychological Medicine
and Out-Patients’ Physician, King’s College Hospital, London.

For several years past my attention has been directed to a series or
cases in which the principal symptom has been the presence of hallu¬
cinations.

Employing the recognised classifications in use in this country, it has
often been a matter of the greatest difficulty to decide under which head¬
ing individual members of this group should be placed.

As the hallucinations give rise to slight depression some might pos¬
sibly be included under melancholia. In others delusions of persecu¬
tion develop and paranoia might be the provisional diagnosis. Others,
again, might be swept into the wide-spread net of dementia praecox.

This state of affairs cannot be regarded as satisfactory, for, as will be
shown later, they are not truly cases of melancholia, paranoia, dementia
praecox or any other described affection.

It is the purpose of this paper, therefore, to attempt to prove that
there are certain hallucinatory cases which can be grouped together to
form a well-defined clinical entity. This I have called “ chronic hallu¬
cinatory psychosis.” The choice of a suitable name is of no small
importance, and the reasons for the selection of this one will be given
as the discussion proceeds.

The main feature of the illness is the presence of hallucinations.
These may be of all the senses, but auditory hallucinations are the most
prominent.

At the beginning the patient may realise that the hallucination is a
morbid phenomenon and unaccountable. He may admit that though
he hears a “ voice ” speaking, there is no one in the flesh actually doing
so. Such a state of affairs may last for years, and possibly, though
rarely, for life, and the subject would not be deemed insane in the
ordinary sense of the word. It is probable, however, that this con¬
dition forms the first stage of the illness, which eventually develops on
definite lines. The patient demands an explanation of the hallucina¬
tions. As none is forthcoming he tries to account for their presence,
and the result is a delusion, and, most frequently, a delusion of
persecution. The point to be noted is that the delusion is a compara¬
tively late arrival and is the logical result of the hallucinations.

Other abnormal mental symptoms in the early stages are, as a rule,
absent. The patient is quiet and orderly. The memory is good, and,

( l ) A paper read at the Quarterly Meeting of the Medico-Psychological Associa¬
tion on February 24th, 1920.

LXVI.

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outside the sphere of influence of the hallucinations, conversation is
rational and little amiss is noticed by the friends.

Before embarking upon a more detailed account it will probably
assist the comprehension of the subject if a few clinical illustrations are
given.

Case i. —M. T—, female, at. 20, single, no occupation. An aunt was insane.
I was asked to see the patient in the autumn of 19x6, as she had been subject to
uncontrollable fits of crying since about Easter, 1916. Though no mention of
hallucinations had been made to me, to the question “ What is the matter?*’ she
immediately replied that she could hear two voices talking to her “ as clearly as
you are talking to me.*’ In reply to the question as to the nature of the messages,
she said “ Hell” and “ other words too awful to mention.” On one occasion she
had seen “ pictures of Gethsemane and other religious pictures.” These were the
only visual hallucinations, and they did not recur. There were no hallucinations
of taste or smell, but she had once the strange sensation “ as if someone were
touching the skin of my body.” On subsequent occasions more information was
obtained as to the content of the auditory hallucinations. She told me she heard
the voices say : " Don’t take no notice.” 11 Mary, it is Satan talking to you.” “ Do
you hear me?” ” You had better kill yourself.” “You’ll be a lunatic before you
are many days older.” When she tried to sing hymns the voice said, ” Oh, shut
up.” On one occasion when I was called away from our interview for a few
minutes I asked her to write down exactly what she heard in my absence, with the
following result: “What do you mean by telling Doctor all I have told you?
Mary, why don’t you take any notice of me ? Go and see your Dad. Mary, don’t
you hear me. What are you looking at P Whatever are you writing down all
this just to amuse? You are a wicked cat. You won’t go to Heaven,” etc.
Except for the fits of weeping, there were no other abnormal symptoms, mental or
physical. She was a happy-looking girl, and no one, not even her own parents, had
any suspicion of the presence of hallucinations.

The case was intensively studied and may be recorded more fully on another
occasion, but for the present purpose it will suffice to state that after several inter¬
views the fits of weeping ceased. Each time she came to see me I explained the
hallucinatory nature of the voices, which she accepted, and as time went on she felt
herself more and more able to disregard them. I found, also, that there was a very
severe secret conflict in the life of the girl which was unknown to her family, and
with the confession of this she improved so much that the treatment was discon¬
tinued.

1 am very sorry to have to report that since this paper was almost completed,
namely, in last December, the patient has found it necessary to return for treatment.
She states, however, that for three years she was entirely free from hallucinations.
The “voices” have now returned with renewed intensity, and I have been able to
discover that the conflict to which reference has been made was not entirely resolved,
and its re-appearance upon the scene has caused the return of the distressing
symptoms.

Discussion .—It is not easy to put a name to this condition. Hysteria
might be thought of and the fits of weeping might easily be termed
*' hysterical,” but their origin was due, as the patient definitely informed
me, to the annoyance caused by the “ voices.” To call the case one of
hysteria or neurasthenia is really only an abuse of these terms and
merely a cloak for ignorance. My own feeling is that it is a case of
chronic hallucinatory psychosis. She was not insane. She did not
-develop any delusions with regard to the voices or herself. She quite
realised that these were abnormal. It is for this reason that I have
adopted the word '* psychosis ” instead of “ insanity.” I would not like

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to hazard an opinion as to what is in store in the future for this patient.
The French call the condition 11 hallucinose and the majority seem to
hold the view that these cases eventually develop delusions. An illustra¬
tion of this is given as Case 3>( s )

Case 2 is similar in many respects to case 1, but is of a more severe
type.

S. S.—, female, act. 38, married, no children. Father suffered from senile insanity.
A half-brother committed suicide. In June, 1914, she fell down the stairs of a motor-
bus and was much shaken. After this she suffered from sleeplessness. About
August, 1914, she and her husband went to live at some flats. The rooms were
close together and she thought she could hear the people talking to each other.
For example, one night she thought she heard one man say to another/ 4 What the
devil did he mean by frightening me about motors.” Owing to her nervous
condition they left the flat and went to Maidenhead, and then to another address.
Here she was 44 delirious ” she said. No one knew, however, that she was
44 delirious.” By this expression she meant that she could hear 44 music in her head
and gramophones talking three or four together. It was like Hell.” The
hallucinations had existed in much the same condition, some days slightly better
and other days slightly worse, till she came to see me in July, 1918. She then gave
a full account of the numerous 44 voices” she heard. I asked were the voices
imaginary and she replied/ 4 I know they are not real, but they are so persistent I
cannot think of anything else.” She was unable to offer any explanation of them.
What led to our interview was the fear that she might lose control of herself.
For example, a voice told her to warn the police that there was a foreigner in the
village she was then living in and she was afraid she might do so. She was
anxious for institutional treatment and at her own request she was certified. She
came to the City of London Mental Hospital, where she was given full parole and
worked on the farm and for a time the hallucinations almost ceased. She had a
slight injury to her foot, and during the enforced rest the hallucinations returned
with increased intensity, and now the chicken and ducks began to speak to her.
She left on trial on November 30th, 19x8, not really any better. At the present
time (November, 19x9) she complains of severe pain on the left side of the head,
44 just like an abscess.” When the sounds come up to the left ear it seems to
cause an awful throbbing. The voices are almost continuous. When asked to
repeat some of the actual words she hears she says, 44 A boy’s voice has just said
4 Some of the dirty little donkeys couldn’t find it out/ and 4 Who would think I
should come down here to make such an enemy as this.*” The second sentence
was said by a boy’s voice a long way off. Birds and animals appear to talk
to her. For example she says, 44 Yesterday the birds said they were sorry they
could not get me into the best society.” She was at a public procession a few
days ago, and a horse appeared to speak quite distinctly to her. A fresh pheno¬
menon is that every movement made by people seems to result in a voice speaking
to her. In order to And out if any delusions were being formed I asked her again
what was her explanation of all this. She said, 44 It’s a nervous thing, a most
mysterious thing.” She admitted that though other people were with her, she
alone hears these different noises. The nearest approach to a delusional inter¬
pretation was her question, 44 Do you think Mr. Maskelyne could cause all this
Dy putting me under his influence?” The hallucinations started in the left
ear, then affected both ears, and now again are chiefly in the left ear. There
have been no hallucinations of the other senses. She lives at home and engages in

(*) As at the time I first saw this patient I was unacquainted with this variety of
illness, I had considerable anxiety as to whether I should recommend that she
should be sent to a mental hospital or not, more especially as the voice once said,
44 Kill yourself.” She had, however, either to remain at home or be certified—there
was no other alternative—and I am now glad I stuck to my guns and kept her at
home. What a case, however, for a psychiatric clinic) May these institutions
soon come)

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her housework, but is easily tired on account of the continual struggle with the
“voices.” Her friends notice little the matter with her except her preoccupied
expression. She says, “ I have two heads. I have a very sensible head, and yet
you would be surprised at what is going on in the other head.” The “ sensible
head” enables her to keep up appearances. This spontaneous expression is
very interesting as indicating that the patient herself has a feeling of dissociation.

Discussion. Here, then, is a patient with auditory hallucinations
which have been in existence for over five years. It is a worse case
than No. i owing to the almost continuous presence of hallucinations.
I am afraid she is beginning to seek for some explanation, which, later
on, may found a delusional system. Except for the severe pain in the
head and the occasional absent-mindedness there are no other mental
or physical symptoms. She converses naturally and rationally on other
topics. At times she looks slightly worried and depressed, but mostly
she is bright and cheerful. She eats and sleeps well.

As regards diagnosis, the remarks made about Case i apply equally
here. As regards causation, one must note the accident. A prolonged
examination into the history of her life has revealed several severe
conflicts, and the investigation is being continued.

The next illustration is taken from French literature. For the
purposes of reference I shall call it Case 3. The following is the
translation of a report ( s ) of a meeting of the Psychiatric Society of
Paris held on June 15th, 1911.

M. S^glas said:" I shall take advantage of the present occasion to give a brief
summary of a new case, the full history of which I shall publish in detail later on.
It is that of a female, aet. 35, who has been tormented for the last five years by
4 voices.’ These 4 voices' are heard in different ways. Sometimes they speak
* mutely 9 to use the actual word of the patient. This is the well-known symptom
of 4 inward voices ’ (voix interteures). Sometimes, on the contrary, they seem to
come from the external world, as though someone were speaking loudly, or more
often with a whispering sound drawing gradually closer to the patient. This
discrimination, quite a spontaneous one on the part of the subject, is very impor*
tant, for it seems clearly to prove in the second variety the existence of halluci¬
nations properly so-called which are exteriorised. The patient adds that then the
voice appears to come from around her, sometimes from the right side, sometimes
from the left, sometimes from below, just as if the speaker were lying down at her
feet on the floor.

44 At the same time she experiences what.has been called the sense of a 1 presence,*
and often also, when the voire approaches to speak in her ear, she feels the
grazing of the actual contact of a body leaning on her shoulder. This sensation
of contact can be produced as an isolated symptom. It can also be exaggerated
as the feeling of a 4 pushing.* At other times she feels in her limbs, as it were, a
4 trifouillage * ( 4 ), which forces her to execute strange movements . . . This

condition has lasted for five years without the patient being able to decide as to
the nature of these 4 voices * of hers. She does not at all realise their subjective
character and will not admit that they come from herself, as they annoy her so
much at the time as to make her angry. On the other hand she does not know
what can produce them, and her ignorance in this respect is well expressed in the
neuter designation which she uses : 4 It speaks to me.’ She has not built up any
system of interpretation regarding them, and even appears much astonished at all

(•) Enciphale , vol. ii, 1911, p. 157.
( 4 ) Untranslatable.

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1920.]

the questions she is asked in this connection. She only repeats that she has many
times asked the * voice ’ what it all meant and that she has never obtained any
reply but this, in my opinion a very characteristic one— 1 Mystery ! Mystery ! *

“ As I have already had occasion to remark, and as M. Buvat has just reminded
you, patients of this kind are to be kept distinct in our minds from those who are
consciously hallucinated—that is to say, those who of themselves realise the
subjective character of their hallucinations. They are also to be kept distinct, on
account of the poverty or even the absence of any attempt at systematic interpreta¬
tion, from the systematic hallucinated insane. However, the character, the con¬
tents and the evolution of their hallucinations seem rather to bring them in near
relation to these latter, to which they are in all probability closely connected by
a series of intermediary cases.”

To those interested in the subject two similar cases will be found in
Atmales Medico-Psychologies^ vol. ix, 1909, p. 256.

Case 4. —This is also from the French, and was brought before the
Society of Psychiatry of Paris in November, 1911, by MM. Louis
Boudon and Pierre Kahn.

“ Mme. F—, aet. 44 years, has shown signs of hallucinations for three years.
Auditory, olfactory, visual, and those of general sensibility have appeared in her
in succession.

“ For more than two years, as MM. Dupr£ and Gelma have said in this place, she
remained simply an hallucinated person without any delusional idea. But at the
present time the clinical picture has changed■ delusional ideas have been added to
the hallucinations.

“ Present condition : Auditory hallucinations. —These do not allow the patient
any peace. Sometimes she hears things of no consequence; most frequently,
however, there are insults or menaces. People reproach her with not loving her
children, with having had sexual relations with a Protestant or with having had
abnormal relations with her husband. They whisper to her villainous things.
Certain hallucinations of an imperative character order her not to rise up from bed,
not to eat, and not to dress herself.

“ Some antagonistic hallucinations advise her not to be uneasy in mind, telling
her she is a well-conducted woman. But in spite of all that ‘it is unbearable to be
incessantly insulted. 1

“ Hallucinations of taste and of smell .—Our patient does not admit any hallucina¬
tions of taste, but she has olfactory hallucinations, and these are generally combined
with those of hearing.

“ Hallucinations of general insensibility. —These consist in sensations of formi¬
cation, of tearing and of * picotements.* These the patient herself often calls by
the name of ' crepillements .’

" Genital hallucinations. —F— complains that persons make her submit to
touchings of the parts.

“ Visual hallucinations .—In the evening at nightfall, but sometimes also in the
daytime, F— again sees people that she has seen on preceding days; occasionally
they appear to her ‘as in a cinematograph/ and when her husband has gone out
she sees him as if he were with her paying visits to the tradesmen of the district.

“Psychomotor hallucinations. —F— complains that people make her execute
movements in spite of herself, and that they compel her to speak.

“ Our patient then is still badly hallucinated. But at the present time the
symptomatology she has presented for some months past is enriched by new
elements which are—

“ First: Delusional interpretations. —It is the neighbours who insult F— because,
she says, she one day refused an invitation addressed to her by one of them. It
is a gentleman whose name she does not know who reproaches her with having
had certain relations with a Protestant. It is eglantinards and freemasons who
speak to her.

“ People magnetise her. One of the physicians who formerly attended her
magnetised her while auscultating her. People have some scientific means by which

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they can make her hear voices at a distance. In the same way, if, while alone, she
sees people she knows, it is that these persons have been given a certain power
( fluide grdce) by which they can reappear before her. We have not ascertained
any ideas of grandeur.

11 Second : Neologisms .—Not numerous, but among others you will remember the
word 4 crtpillements ' by which F— names certain of her hallucinations of general
sensibility.

“ Third ; Reactions in opposition to her persecutors .—These have diminished to
a great extent.

“ However, F— answers the insults that she hears and often gets angry. She has
told us of her intention to change her residence when she leaves the asylum. She
requested her husband to lodge a complaint at the police station against her
persecutors.

“ Lastly, she has come to us hoping that physicians would be able to instruct her
as to the proper scientific means to thwart those of her enemies.”

It may be as well to pause here for a moment to review the ground
covered so far. The first case is that of a patient who was completely
aware of the abnormal character of the hallucinations. The second
is of a more severe type. The patient had at first distinct insight as
regards her condition, and for many years has been able to live among
her neighbours without their noticing anything amiss, but she is now
beginning to lose touch with her environment and is afraid of herself.
Delusions seem to be on the point of developing. The third patient
has not developed delusions, but has no insight of the nature of her
illness. Case No. 4 is one in which definite delusions have developed
in a person who for many years had hallucinations only.

The following and last case is an example of the same sequence in
one of my own patients. I have selected this one as she has been
under observation for some time.

Case 5. — C. N. C — , female. Admitted to the City of London Mental Hospital,
January 6th, 1915. Single; governess. Father alcoholic. Father’s brother
died insane. One sister insane, a second sister unstable, a brother died insane,
another brother died from alcoholic excess, another brother had a drug habit.
Father and mother are dead, and she had been living quietly with a sister at
D—, going out as a daily governess.

In the summer of 1912 a brother, F. C. C—, to whom she was very attached,
was missing for several weeks. She and her sister were daily expecting his
arrival, and no news was received from him. As far as can be ascertained he was
in trouble with the police, and shortly afterwards fled the country. While in this
state of anxiety, in September, 1912, she consulted Dr. D— about a small growth
in her gum, and continued going to see him for about two months. Shortly after
her first visit to Dr. D— she began to hear “ voices.” At first she thought it was
his voice. About the same time she commenced to have strange sexual feelings
which she attributed to Dr. D—. The hallucinations continued during the winter
and spring, and in the summer of 1913 she went to some relatives at F— and
the voices were not so persistent as at home, but it was here that “ nasty words M
began to come— 11 such nasty words.” She gave up teaching during this summer,
but resumed this in the winter, and finally ceased her work in August, 1914.
About this time, also, it seemed as if ” thoughts ” came to her from other people,
and that other people could read her thoughts. In November, 1914, she had the
visual hallucination of seeing Dr. D—. To use her own words, “ Quite plainly
I could see his presence beside me. I was talking to my sister one night and not
even thinking about him, when his presence seemed to be standing quite close ta
me.”

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Condition on admission .—She was a quiet, lady-like patient, and conversed in
a natural manner and rationally. Her memory was excellent. I asked her to
write down the actual words she heard, and she gave me two closely-written sheets
of notepaper, too long to quote, but containing, amongst others, the following
words : “ Eternal weary man,” “ Too rummy,” “ Too guarded,” “ Can't beat it,
"Booby,” " Get thinner,” "Unhealthy yet married,” “Tea," “Cursed in spite,”
" Hoodwink." " Beat her, bruise her," etc. She had also the " echo "-sensation
of hearing her thoughts spoken aloud. There were no hallucinations of the other
special senses. Besides the hallucinations she complained bitterly of the sexual
feelings.

During the last five years there has been but little real change, though she is at
times worse than others. Mostly she is industrious, but at other times refrains
from all work, as it does not seem to further her discharge. At first she could offer
no explanation of the hallucinations, but she has now formed the delusion that she
is being persecuted by some unknown agency. She is seclusive and rather avoids
myself, as she thinks 1 ought to take active measures to stop this persecution.^)

It is interesting to note that a sister, who is still engaged in teaching, and whom
no one seems to suspect of being mentally affected, as long as three and a-half
years ago told me that she heard my voice talking to her all the way in the train
as she was travelling up to London.

Discussion. —Here, then, is a patient who, since 1912, has been the
subject of auditory hallucinations. Arising from these, delusions of
persecution have developed in a logical manner. These delusions are
vague, and have appeared only as a late symptom, and there are no
signs of dementia.

The illness came on after a period of severe anxiety. About the
same time she consulted a doctor whom she fell in love with. Her
symptoms and the analysis of her dreams clearly proved this to be the
case. Both the disgrace of her brother and her love for the doctor
were strongly repressed, and, to my mind, this repression caused the
auditory hallucinations. This, however, is another matter which will
be considered later when the aetiology of the disease comes under
discussion.

The point we are most concerned with at present is—“ What is the
diagnosis?” The seclusiveness suggests dementia pnecox. Against
this there are absolutely no other signs or symptoms of this disease.
The predominance of the hallucinations rules out paranoia.

A systematic description may now be attempted. This will be made
as brief as possible. Some amount of repetition will be unavoidable
and, it is hoped, will be excused.

✓ Etiology .—In most cases a careful research into the family history
will reveal a strong hereditary tendency to nervous instability. This is
particularly well marked in Case 5. A statistical inquiry at this stage
is premature, as the numbers known to any single observer are few.
It is not to be inferred, however, that it is a rare disorder, for I can
select half-a-dozen or more with the greatest ease from my own practice.
Without statistics, then, my general impression is that the affection is

(») This patient now complains that she hears " silent voices "—her own expres¬
sion. Compare Case 3.

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one of adult life and begins mostly between the ages of thirty and fifty.
Most of my patients have been women, and it is more frequently met
with in the private than the rate-paid class.

Other observers have suggested that an illness such as pneumonia
may act as a predisposing cause. Such, however, has not been my
experience. As regards the actual cause, it may be noted that a history
of physical injury is often met with. In Case i, for example, she dated
all her troubles from the time when some fire-irons fell on her ankles.
In Case 2, it will be remembered, the patient fell down the stairs of a
bus. Though a physical trauma may play some part as a precipitating
factor, I feel that the main cause is psychical. In all cases which I
have studied intensively, I have found evidence of severe mental
conflict with more or less repression of the same.

Pathology .—There is no known special morbid anatomy. Not one
of my cases has died, and other observers have published no accounts
of post-mortem examinations so far as I am aware.

The conception of the real nature of the illness will depend on the
theory of hallucinations in general. Such a theme would suffice for
many papers. Though the following statement sounds dogmatic I
hope it will be forgiven, as in the interests of brevity I have tried to
make it as concise as possible.

There are many theories with regard to hallucinations founded on a
material conception, and so far no centrifugal, centripetal or special
centre theory has met with general acceptance or advanced our
knowledge in the least degree.

The nature of the phenomenon can be best understood if approached
from the purely psychical side. An hallucination is the result of
dissociation of the mind. As to what is meant by this, the following
examples may be given: When a man reads aloud and his thoughts
wander to other matters there is a small amount of dissociation. A
greater degree is met with in automatic writing. Other examples could
be given showing increasing severity till the extreme limit of the
multiple personality is reached. In chronic hallucinatory psychosis
dissociation of the mind has taken place. This dissociation has been
caused by mental conflict more or less repressed in a person con¬
genitally mentally unstable. It is noteworthy that the patient may
possibly have a feeling of dissociation. An example of this has been
given in Case 2.

Symptoms and course .—After a. period of some mental uneasiness,
and possibly sleeplessness, an auditory hallucination appears with
startling suddenness. The patient is naturally astounded. Other
auditory hallucinations follow rapidly and cause a certain amount of
distress. At first it is admitted that these hallucinations are “ imagi¬
nary ” or “ not real.” These are the expressions used by the sufferers

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107

1920.]

themselves, and though, strictly speaking, not very accurate ones, they
convey to our minds the fact that the patient realises he is dealing with
something abnormal in his personality. At a later stage he abandons
the position that the voices are subjective and states that they are
produced externally by some unknown agency. In a word, insight is
now at an end. The final stage is, that the unknown agency is now
known, and consists of “ freemasonry,” “ wireless telephony,” “ a gang
of persecutors,” etc., and the patient is now the subject of hallucinations
plus delusions. The delusions, moreover, are the logical product of
the hallucinations. The hallucinations do not differ in any marked
manner from those met with in order forms of insanity. They may be
of all the senses, and auditory are most frequent, visual least so. One
very painful feature is that the voices convey messages of an obscene
or blasphemous nature. With regard to the sensation of touch, a
symptom which causes intense distress is the hallucination that the
genital area is being touched or interfered with. A strange hallucina*
tion is that of someone being present in the room—not seen, or heard,
or felt, but just a feeling as if there were a “ presence ” near. In some
cases the hallucinations may be continuous while the patient is awake.
They cease during sleep, but immediately reappear on awakening either
in the middle of the night or in the morning. Sleeplessness is not a
prominent symptom except in the later stages of the disorder.

During the first part of the illness, for many months, or even years,
other mental symptoms are absent. The general behaviour in no way
attracts attention. The expression is normal, conversation is quiet,
rational, and without loquacity or retardation. The memory is excellent,
emotional excitement rare and depression only slight. In short,
outside the sphere of influence of the hallucinations there is nothing
that can be taken exception to. Later on, as the hallucinations with
their delusions assume the control of the personality, many symptoms
arise. The expression becomes anxious. A listening attitude may be
adopted and the “ voices ” may be conversed with. Memory for recent
events may be poor, because the attention is distracted. Conversation
is to a considerable extent confined to the hallucinations and delusions.
Letters may be written to the Home Secretary or other important
personages. The police are asked why they do not interfere to stop
the persecution. Violence may be threatened and suicide suggested.
The extent and severity of these symptoms will depend on the hold the
delusional system has obtained. This may be put in other words,
using the illustration of Case a, who said that her mind was divided
into two parts—a “ sensible ” and a “ bad ” one. At the beginning the
"sensible” part is by far the larger and can easily control the aber¬
rations of its fellow, but as time goes on the former shrinks pari passu
with the increase of the latter and the symptoms mentioned appear.

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The whole process is very gradual, hence the name “ chronic.” It is
not strictly continuous, as there are periods of remission and exacer¬
bation, with again subsidence, but viewing the illness as a whole it
steadily increases in intensity. Having reached its maximum, the
severity of which varies in different subjects, the condition remains
stationary for years. Possibly I have not observed the cases for a
sufficiently long time, but I have not seen the development of delusions
of grandeur followed by dementia as described by some authors.

Diagnosis .—Hallucinations occur in all forms of mental disease and
are probably the commonest symptoms met with. It is therefore
evident that the mere presence of hallucinations will not suffice for
diagnosis. In chronic hallucinatory psychosis, however, the disorder
begins with hallucinations, and the patient outside the sphere of these
appears to be normal, so that in the early stages the diagnosis will be
simple. In the later stages, this will have to depend to some extent
upon the history of the illness and may not be so easy a matter. But
if the delusions appear to be the logical outcome of hallucinations which
have preceded them, and that if outside the diseased area composed of
hallucinations and delusions the patient appears but little abnormal, the
diagnosis will be made.

Differential diagnosis .—If these main points are remembered there will
be little difficulty in excluding general paralysis, the manic-depressive
group, true melancholia and the secondary and organic dementias.
Neither need acute confusional insanity, also called acute hallucinatory
insanity, detain us as it is altogether different. Chronic hallucinatory
insanity of alcoholic origin has many points of resemblance to the dis¬
order under discussion, but in the former there is a history of alcoholic
excess for a long period, in the latter this is wanting. Moreover, in the
alcoholic, the delusions of persecution are more pronounced and appear
at the same time as the hallucinations.

In practice, however, the temptation will be to include the cases we
have been considering under the heading of dementia prsecox, or paranoia.

To take dementia prsecox first. No doubt many cases similar to
those I have described have been squeezed into this category because
there was no other place for them. It has ever been the bane of our
specialty that it has suffered from nosological fashions. When a certain
clinical entity looms largely before the eyes of the practitioner it becomes
the universal disease. To-day it is dementia prsecox, and I think it will
be admitted by all that we have to be constantly on our guard so that
we do not diagnose dementia prsecox in cases which our present
ignorance should urge us to deem as unclassifiable. There are testily
very few points of resemblance between chronic hallucinatory psychosis*
as I understand it, and dementia prsecox. It is true that in the para-
noidal form there may be delusions of persecution with hallucinations.

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But these delusions are not systematised nor are they the logical outcome
of the hallucinations. They are constantly changing and have that
“freaky” character common to dementia prsecox. Furthermore, a
typical case of this latter disease with its emotional apathy, lack of
judgment, scattered ideation, and all the peculiar behaviour such as
impulsiveness, negativism, stereotypy, mannerisms, monkey tricks and
the rest, bears no resemblance to one of chronic hallucinatory psychosis.

Lastly there is the question of paranoia, and this cannot be dismissed
so summarily. In both paranoia and chronic hallucinatory psychosis
the beginnings of the illness may be unnoticed for years by the friends
of the patient, the evolution is slow and gradual, and outside the sphere
of the disorder the patient is well conducted, collected and rational in
conversation. In neither, even after long periods of time, does dementia
supervene. There is, however, this great distinguishing feature—that
paranoia is characterised by the absence of hallucinations, and in chronic
hallucinatory psychosis the presence of hallucinations is the main sym¬
ptom. I could give numbers of references from various writers to show
that they regard almost as pathognomonic of paranoia the fact that
hallucinations are absent. Perhaps one will suffice: Kraepelin, in dis¬
cussing the differential diagnosis of genuine paranoia and dementia
prsecox, states that the former do not suffer from hallucinations.^)

Someone may say, “Why not call this new disease 'hallucinatory
paranoia’?” and in some ways such a course would be plausible, but it
seems to me contradictory to set out to describe an hallucinatory form
of a disease which is characterised by the lack of hallucinations.

Before concluding the differential diagnosis reference must be made
to descriptions given by various authors of disorders which more or less
resemble chronic hallucinatory psychosis.

From a large list I have selected the following three:

First of all must be mentioned the Laslgue-Falret syndrome, which
dates from the middle of last century. This consists, to put it very
briefly, of four stages. In the first, delusional interpretation of the
environment occurs; in the second stage hallucinations develop;
in the third stage disturbances of general sensibility arise; and the
fourth stage is characterised by the formation of delusions of grandeur.

Later on came Magnan with his description of dilire chronique
This, like the last, has four stages also: First stage —suspicion of
the environment with delusions; second stage —hallucinations with
systematisation of the delusions; third stage —delusions of grandeur;
fourth stage —terminal dementia. Most writers agree that a typical
example of Magnan’s disease is rarely seen, and regard it more as a
schema to which various cases approximate more or less accurately.

(*) Dementia Preecox, Kraepelin, translated by R. Mary Barclay, p. 376.

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[April,

Finally mention must be made of Kraepelin’s paraphrenia, a full
account of which is given as the terminal chapter of Dr. Mary Barclay’s
translation of Kraepelin’s dementia praecox. This conception seems to
be founded largely on Magnan’s dilire chronique , which it resembles in
many respects.

Time does not permit of a detailed differential diagnosis of these
from chronic hallucinatory psycbosis.( 7 ) It will, however, have been
noticed that in them delusions of persecution form the main feature of
the illness and that these delusions appear prior to the appearance of
the hallucinations, whereas in chronic hallucinatory psychosis the
reverse is the case. Furthermore, in the latter delusions of grandeur
and terminal dementia do not occur.

Prognosis .—The earlier, the case is seen the more hopeful is the
outlook. After the development of delusions little can be done to
avert chronicity. The general health is not affected and there appears
to be no danger of terminal dementia.

Treatment .—In the early stages benefit is sometimes obtained by
change of environment. Rest from work, freedom from anxiety and
change of air and scene should be advised; these measures, with plenty
of nourishing food, relief of constipation if present, tonics and an occa¬
sional hypnotic to ensure sleep may do good in some cases. I have
not much faith in the efficacy of any particular drug to remove hallu¬
cinations. Small doses of the bromides or hydrobromic acid have been
recommended. If the patient does not improve under this treatment a
thorough mental examination must be undertaken. This will, almost
certainly, reveal a conflict, which, with repression of the same, is causing
the dissociation. Even then the work may not be at an end and a
psycho-analysis will be necessary. The difficulty at the present time is
to get in touch with the patient in the primary stage. Even now, how¬
ever, some do come to the mental out-patient departments of the large
hospitals and in the future many more will be met with in the clinics.
When the patient reaches the stage when he has to be certified the
whole morbid state has become so fixed as to be little affected by
analysis in the majority of cases. Even then, however, this should be
undertaken with a view to the study of the mechanism of the process.
If it be generally confirmed that dissociation is the pathology of the
condition then we might expect that hypnosis would be beneficial, seeing
that Morton Prince produced recovery in the classical case of Miss
Beauchamp (a dissociated personality) by this means. On this matter
I cannot speak from personal experience.

( 7 ) This matter is discussed in considerable detail in a paper by Roxo on " Dllire
Systematise Hallucinatoire Chronique,” read at the International Congress of
Medicine in London, 1913, and published in the Transactions, section " Psy¬
chiatry,” Part II, p. 104.

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When the condition has become chronic little can be done save to
treat the patient on general lines, and by means of suitable occupation
to prevent him from becoming worse.

In conclusion, I would venture to suggest that the subject of the
hallucinatory insanities should receive more attention in England in the
future than has been the case in the past. If the medical journals of
other countries, notably those of France, are studied numerous papers
and discussions on these matters will be found in them, and yet in this
country they are rarely mentioned. The subject is undoubtedly a diffi¬
cult one, but it appears to me that out of the mass of somewhat con¬
fusing material the disorder I have tried to describe can be separated
as a definite clinical entity. It may seem to some a matter of indifference
what nomenclature is adopted. This, however, to my mind is most
important, for with recognition and naming come investigation on
definite lines.

I am therefore expressing the hope that others will follow suit on the
same lines, and that by additional intensive study many gaps in my
description will be filled in, and that eventually with timely recognition
early treatment may lead many patients to recovery.

Head Injuries in Relation to the Psychoses and Psycho-neuroses.(})
By Richard Eager, O.B.E., M.D.Aberd., Senior Assistant
Medical Officer and Deputy Medical Superintendent, The Devon
Mental Hospital, Exminster; late Officer in Charge of The Mental
Division, The Lord Derby War Hospital, Warrington.

Until the outbreak of hostilities in August, 1914, the number of
cases of mental disorder associated with head injury investigated by
any one individual must of necessity have been very small. Hence the
sparcity of literature on this subject. Never hefore the outbreak of the
late war have so many men been engaged in armed conflict against one
another, and never before have arms of such a destructive kind been
employed.

Comparatively suddenly, therefore, we are brought face to face with
a large number of men receiving terrible injuries to the skull and its
contents, the like of which has never before been known. Thanks to
the high standard of efficiency of modem surgical methods a large
number of these cases have been restored to a condition fitting them to
become useful citizens, but on the other hand the ultimate condition of
some has not been such a favourable one, and it is with regard to these
cases that I am confining my remarks in this article.

For a period of two years, during which I was in charge of the
Mental Division, comprising 1,000 beds, at The Lord Derby War

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HEAD INJURIES IN PSYCHOSES,

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Hospital, I have kept personal records and observations on all cases
with head injury that were admitted, and it is from the study of this
collection of cases that the following observations have been made.

In reviewing the cases of head injury met with surgically by Lieut-Col.
Gordon Holmes and Lieut.-Col. P. Sargent up till September, 1916,
they stated that the proportion of cases in which insanity or epilepsy
had developed was surprisingly small.( 1) They state that many patients
presented symptoms of dulness, loss of memory, irritability and childish¬
ness during the early stages, but in the majority of cases these symptoms
disappeared or diminished. That during a period of twelve months
only eight patients who were wounded in the head were admitted to the
Napsbury War Hospital as mental cases, and four of these had since
been discharged. Of the four others one had been previously invalided
from the army for mental trouble but had re-enlisted, a second was
considered to be a case of dementia praecox, and in the two remaining
cases only were the persistent mental symptoms attributable to the
head injury.

Cecil A. Joll (2), from a series of twenty cases, states that two cases—
both French—showed “ mental instability.” One of these was a case of
cerebral abscess following shrapnel wound penetrating the left parietal
region, and the other a glancing bullet-wound of the left parietal region.
There were also two cases with symptoms of delirium—one of these
a German with shrapnel wound of the right side of the fronto-parietal
and occipital regions, and the other a Frenchman with a glancing bullet-
wound of the right parietal region near the vertex. A sixth case, a
Frenchman with a glancing bullet-wound in the posterior parietal
region, showed maniacal symptoms, and another case was hopelessly
demented.

Such information as the above is too scanty, and based on an
insufficiently large amount of material to be of much value. I think,
however, that by making an analysis of the first hundred consecutive
cases of head injury in which mental symptoms had manifested them¬
selves, and therefore led them to be placed under special observation,
we shall find points of interest to the alienist.

No case was considered by me as a suitable case to include in these
observations unless there was clear evidence that a definite head injury
had been received. All cases therefore which gave “a history” of
head injury which could not be corroborated by examination or
accompanying notes were carefully excluded from my series. Most of
us who have inquired very deeply into the personal histories of our
patients will be familiar with the frequency with which one obtains
vague accounts of alleged head injuries as an endeavour to account for
the mental symptoms, and nothing could be gained by inclusion of such
cases in this record.

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BY RICHARD EAGER, M.D.

11 3

A large proportion of the cases from which the material for this
article was obtained had injuries of a very definitely severe and terrible
nature. They were all taken from a series of over 5,000 cases of war
psychoses that have now passed through my hands during the same
period.

These cases will now occupy our attention, and individual case-
records will be quoted as freely as space will permit.

In classifying head injuries Purves Stewart (3) divides them into
(1) tangential, (a) penetrating, (3) perforating, but for the purpose of
this paper I have divided my cases into “superficial” and “deep.”
By the former I mean, and have included, cases in which after thorough
examination nothing more than a superficial wound involving skin or
subcutaneous tissues was found. In the latter class I have included
any cases where there was injury to the skull or underlying structures.

The table shows the 100 cases accounted for in the above manner,
and grouped together according to their symptoms and the topographical
distribution of the injury.

It is seen that practically half the injuries were of the superficial
character, and in the other half the skull or underlying structures were
involved in the injury. On looking further into these cases it was
also found that 50 were left-sided injuries, 35 were right-sided, and
the remaining 15 were confined more or less to the middle line or else
involved both sides of the skull.

There is at first sight seen to be a striking conformity between the
superficial and deep injuries with regard to the type of cases presented
in each group. There was in fact no marked disproportion of cases in
either with the exception of the epileptics. Here, however, we find
that 12 out of 15 cases occurred in the injuries involving the skull
or underlying structures. In other words, whereas the cases of epilepsy
represent 15 per cent, of the total number of cases investigated, the
incidence of epilepsy was four times greater in the cases with gross
cranial injury than in the cases in which the injury was of a superficial
character. In one of the cases included in the latter group also it
should be mentioned that it was elicited that the patient had had fits
prior to enlistment. Sargent and Holmes, who made investigations into
cases of head injury in a much earlier stage than those included in this
article, mentioned the comparative rarity of epileptic seizures following
head wounds. They found that fits had occurred only in 6 per cent, of
the cases.

On looking further into the figures in the table it will be seen that
the cases of dementia precox and organic dementia, of each of which
there were two representatives, all figure amongst the deep injuries.

One of the former had been two years in an asylum prior to joining
the Army, and had received his head injury when a child. The other

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114

HEAD INJURIES IN PSYCHOSES,

[April,

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The word “ superficial ” has been used to denote a scar with no indication that more than skin and subcutaneous tissues were involved.
The word “ deep ” has been used to indicate that the wound damaged the skull-bones, and in many cases the underlying structures were
also involved.

BY RICHARD EAGER, M.D.

115

1920.]

bad received a bullet-wound of the mastoid region of the skull in
action, and had had the bullet removed by operation, but being a
Canadian no accurate account of his previous history could be obtained
from any relatives, and during the three months that he was under
observation awaiting repatriation it was quite impossible to obtain
any reliable information from the patient himself. He could not even
give his home address, and frequently was altogether mute in response
to questions, but sat muttering a great deal to himself, and occasionally
bursting out into senseless laughter. He was also catatonic, and
presented most of the symptoms of dementia praecox. Capt. H. J.
Norman (4) has previously described a case in which the symptoms
of “dementia praecox” developed after a compound fracture of the
skull over the right Rolandic area, with opening up of the dura and
laceration of the brain causing hemiplegia. In my case just recorded
the bullet was removed from the left temporo-sphenoidal region about
1 in. behind the left ear, where it had lodged without any evidence of
penetrating the internal table of the skull.

The two cases of organic dementia were both associated with severe
cranial injury. In one the injury was of sixteen years’ standing, and
in the other the patient had metal in the right cerebral hemisphere,
with a destruction of brain-tissue causing a left-sided hemiplegia.

The cases of mental deficiency had all been below the average in
intelligence prior to enlistment, but there was evidence to show that
the injury bad somewhat lowered their pre-war standard. One had
been reduced to the level of an imbecile who was quite unable to look
after himself in any way since receiving a superficial wound of the
scalp of the frontal region. He had previously earned his living as a
carter. Another, after nine months’ service, received a fracture of his
skull from a bullet. He was in hospital about six weeks and discharged
to his depot, but found unable to understand hardly anything that was
said to him, and on this account had to be sent to hospital again.

It will be seen, on the other hand, that all the cases described as
morally defective had injuries of a superficial nature.

I now propose to deal with the analysis of these cases more closely
under groups made in accordance with the site of the injury.

Frontal Injuries.

Of the 100 cases it will be seen that 28 were frontal injuries. Ten of
these were left-sided, 10 right-sided, and 8 over the middle line.

It will be noted that only one case of epilepsy is accounted for in the
frontal injuries. This was the case of a man who died in a condition
of status epilepticus lasting four days. He had received a gunshot
wound of the right frontal region twelve months previously, for which

LXVI.

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he had subsequently had a trephine operation and a frontal abscess
evacuated. Since then, and four months after the injury, “ fits ” had
developed. He subsequently had two attacks of status epiUpticus ,
after which on each occasion his mental condition showed definite
deterioration with marked memory defect. He came under my observa¬
tion a few days after the second “ bout ” of fits, and died a month later.
A post-mortem examination was performed, and a trephine opening
measuring 1} in. transversely and a in. from above downwards was
found in the frontal bone \ in. above the right eyebrow. The margins
of the trephine opening were smooth, and the opening was occluded
by dhra mater. The pia arachnoid was found adherent to brain over
the first, second and third frontal convolutions of the right hemisphere,
and the surface of the brain substance over this area was yellow in
colour. On section the grey matter of the external surface of the
right frontal lobe was practically disorganised; but on the other hand
there did not appear to be any involvement of the white matter as far
as could be seen macroscopically. No metal was present in the skull,
and the rest of the brain appeared to be in a healthy state. The weight
of the brain was 57 oz.

Whereas the number of cases of epilepsy amongst the frontal injuries
was low and limited to one case only, the number exhibiting states of
complete dissociation, such as amnesias, was found to be comparatively
high. Half of the total number of cases in which this was the pre¬
dominant symptom were found amongst the injuries of the frontal
region. In three of these cases the period of amnesia had lasted for a
month and upwards, and in the other three the amnesia was of shorter
duration but recurring at frequent intervals. Most of these cases
complained of a feeling of pressure in the head as an associated symptom.
In only one case could alcoholic intemperance be found to be an
associated factor. The following is a typical example of one of these
cases with amuesic fugues.

Patient was wounded in the forehead by a shell from a trench mortar
whilst coming out of a sap. He was rendered unconscious, and came
to himself the following morning whilst in a field ambulance. He was
only kept in hospital three or four days, and rejoined his battalion in
the trenches two months later. Three months after this he was again
wounded and evacuated to England, the wound on this occasion being
in the elbow. This eventually healed, causing no disability, and he was
given ten days’ furlough in order to proceed home to Ireland to visit his
mother. Two months later he was found by the police in civil clothes.
He stated that he was on his way to report himself to his unit when
arrested, and this appeared to be the case, for on examination medically
it was found that he had a complete amnesia as to what had happened
from the time of his arrival in Belfast till two months later when he

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117

had “discovered himself” on Clapham Common. He then found
himself in civil clothes, but had no idea where he had obtained them.
In his pocket he found a “ pass ” giving him authority to proceed
to Ireland, and instructing him to report at his depot at the expiration
of his furlough. He remembered landing at Belfast, but everything
else seemed "blank,” and he could not remember whether he had seen
his mother or not, for which purpose he had proceeded to Ireland.
Having no money in his pocket he proceeded to walk to his depot,
and it was whilst so tramping that he was arrested. He complained of
a feeling of a painful tight band round the forehead, and that on
previous occasions, whilst in the trenches and since his head injury,
he had had feelings that certain days were “quite blank.” He was
somewhat depressed, and seemed to have considerable anxiety as to
whether he would fall a victim to another of these attacks. On
examination of the skull a definite bony ridge could be felt on the
centre of the forehead extending to about 1 in. above the centre of
the left eyebrow. X-ray examination confirmed the presence of a
definite fracture which had apparently escaped detection previously.
One other point is worth notice, namely, that the only two cases
recorded under the heading of delusional states occurred amongst the
frontal injuries. One was a superficial injury and the other deep. In
the latter case the delusions led the patient to believe that he was
being looked upon as a German spy, and these ideas developed within
four months of receiving a fracture of the frontal bone by shell. The
other case developed ideas that his correspondence was being tampered
with, and that some unseen agency was working against him. This
patient had received a frontal injury twelve months previously, but the
above ideas did not develop till he was again in hospital with a wound
of his hand. It will be observed that two of the three cases of mental
deficiency had frontal injuries, whereas none of the cases in which
the moral side of the patient’s character seemed to have been chiefly
affected were associated with injury of the frontal region.

Our conception of the consequences of frontal injuries prior to the
war was based on the work of Ferrier, Horsley and others who have
contributed particulars of isolated cases. But the opinions expressed
were somewhat indefinite. Ferrier found no appreciable result by
stimulation and extirpation of the anterior part of the frontal region in
monkeys, but his experiments tended to show that on removal of this
area such animals appeared to be more restless and more easily
distracted. It also seemed that under prolonged examination before
and after the experiments there seemed to be a distinct loss of the
persistence shown by monkeys with extirpated frontal lobes to obtain
things, such as a nut, in comparison with normal monkeys. In the
celebrated crowbar accident due to the premature explosion of a charge

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of dynamite in an American mine (5), we are told that the patient
recovered and returned to his work as overseer of the mine, but that
there seemed to be a change in the man’s mental qualities comparable
to Ferrier’s observations on monkeys and a deterioration of moral
character. Oppenheim (6), in discussing the localisation of the cerebral
cortex, says : “ To all appearance the frontal lobes play a prominent part
in the higher mental functions, and excision of a tumour compressing
the frontal lobe has been followed by the disappearance of mental
symptoms.”

From the cases that have passed through my hands, however, there
seems to be no uniformity in the psychic symptoms that may follow
frontal injuries, and the tendency that there has been in the past to
consider as a special characteristic of injuries in this region the likeli¬
hood of the moral character of the individual to suffer most is not
supported.

Parietal Injuries.

These account for 38 out of the 100 cases. Amongst this group we
find 12 out of the 15 cases of epilepsy, all of which were associated
with some gross head injury, except one in which the wound was
superficial. In the majority of cases the injury of bone was so extensive
as to be almost incredible. Fig. 1 illustrates a case with a trephine
opening about 2 in. in diameter over the upper part of the right parietal
region involving part of the Rolandic area. This was the result of a
shell-wound received in February, 1917, whilst sniping in Mesopotamia.
He was ten days unconscious, and after operation was evacuated to
Bombay, where he arrived on March 21st, 1917. About four days later
he had his first fit, the wound being then practically healed. He was
returned to England and received in hospital here about the middle of
September, 1917, when he had a depression over his' parietal bone corre¬
sponding to the site of the trephine opening, and also showed evidence
of a left-sided hemiplegia. As regards this he showed signs of improve¬
ment in the upper extremity, but with the exception of slight movement
in the hip the lower extremity was completely paralysed. There was
no facial or oculo-motor paralysis, and sphincter control was not
affected. His physical condition improved to the extent of enabling
him to be up and about with full power of his arm, but still a slight
paresis remained in the leg. Towards the end of October, 1917,
however, he had a succession of fits in which the convulsions were
generalised in character, and these were followed by an outburst of
maniacal excitement. This condition lasted a few days, when he
showed a certain amount of clouding of consciousness for the period
covered by his maniacal attack, but was otherwise free from any
symptoms. His chief complaint was of pain localised to the frontal

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region, chiefly over the left eye. He said the pain was made worse by
any exertion, and he could not stand any noise. Just preceding the
fits he had hallucinations in the form of the sound of bells ringing in
his ears, and then his sight seemed to go dim. In the course of the
next three months this patient only had one fit which was not followed
by any period of excitement.

The frequency with which epilepsy followed gross head injury in the
parietal region amongst the cases which came under my notice corro¬
borates the results already published by Roeper. (7) The only case in
which there was no evidence of the skull being injured was that of a
man who suffered from concussion following a collision with another
man on a motor bicycle whilst despatch riding. No fracture could be
detected nor was there any external indication of any injury to his head.
He had, however, a small septic wound below the ramus of the lower
jaw on the left side of his neck. He walked with a very pronounced
limp on the right foot, and on examination there was an apparent
shortening of the leg on this side. This was on further examination
found to be accounted for by a tilting of the pelvis to overcome a
paresis with slight foot-drop. This patient on admission also showed
some right facial and arm paresis, and fits of a definite epileptic nature
started three months after the accident, recurring singly at intervals of
about a month. Although I think there can be little doubt that this
case had an organic basis, probably of the nature of a haemorrhage
about the surface of the left Rolandic area, I am also of opinion that a
functional element was superimposed, and that his gait was steadily
progressing towards one of those “ habit gaits ” which have been dealt
with very fully by Roussy. (8)

On referring to the table we find in the parietal region the only case
of mental deficiency outside those already included in the frontal
injuries. After having been repeatedly rejected as unfit for service this
man had eventually managed to enlist in October, 1915. He went to
France, and in July, 1916, was struck in the head by a bullet, receiving
a fracture of his left parietal bone when trying to get water from a shell-
hole. He complained of headache and dizziness and was found to
have a well-marked paresis of the left facial nerve and to be quite deaf
in the left ear, but apart from a pronounced mental deficiency showed
no other symptoms. Prior to enlistment this man had spent his life as
a hawker, but had never learned to read or write. It appears, however,
that his mental defect must have been somewhat exaggerated after his
head injury, for whereas he had previously been sent overseas, on
return to his depot for duty after his head injury he was at once sent
to hospital again, and it was in this way that he came under my
observation.

It is in this group of parietal injuries that we find three of the four

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cases classified as moral deficiency, in which the moral side of the
patient’s character seemed to be the most seriously affected.

One of these cases was wounded by a shell splinter just above the
right ear. He was for the moment dazed, but was able to walk to
the dressing-station. He was sent to the base, but only kept there
a few weeks and rejoined his unit again two months after being
wounded. Here he is now noted as showing marked insubordination,
and his O.C., in making a note with regard to him, says “he has
quite changed in his character since his head injury,” and he is
further described as laughing in his officers’ faces on parade and
seeming to have lost all sense of discipline. This man had eight
years’ colour service with a good character and freedom from any
crime or tendency to intemperance, but since his head injury had
taken to drink on the slightest provocation and seemed to have no
power to resist the temptation. Further inquiry from his relatives also
elicited the information that prior to his head injury he had been
a staunch teetotaller and a very steady man in every way, and bis
character now seemed quite the opposite. This man had received
his promotion to the rank of corporal in France due to his steadiness
in action, and since his head injury had been reduced to the ranks.

Another case was that of a boy, set. 19, who was wounded by bullet
over the upper part of the left parietal region when sniping in a shell-
hole near Guillemont. He had been promoted corporal eight days pre¬
viously, and the good character given him by his father and other
relatives when questioned about his former morals was supported by
the schoolmaster of one of the large public schools where he had been
educated, as well as the head of an agricultural college-where this boy
was learning farming when he enlisted. Whilst in hospital a few weeks
after being wounded this boy became restless and showed extreme
irritability. He demanded to go home before his wound was healed
and threatened to run away if his request was not acceded to. He
lacked self-control, and threatened to strike anyone who “ crossed ”
him in any way. These acute symptoms to a great extent subsided,
but he subsequently showed a type of “pseudologia phantastica’’
which it would take far too much space to enter into here. He was
a notorious liar and full of deceit in every conceivable way. No
reliance could be placed on anything he said or did, and his father,
who, against advice, took him home, had to return him again to
hospital owing to his kleptomania tendencies, stating at the same time
that his character had quite altered to what it was prior to his head
injury.

The third case was that of a Canadian, who apparently had always
been somewhat below the average in intelligence. He received a
shell-wound of the right parietal region after two years in France and

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was unconscious about two hours following the wound, which, however,
on examination proved to be only of the nature of a scalp wound about
a in. long. He was subsequently returned to his unit, when he exhibited
a change in his moral character. His O.C. reported that before his
head injury he was a well-behaved soldier, but since then had been
most unreliable, had had three court-martials, and practically lived in
detention. No punishment seemed to make the slightest impression
on him, and he had taken to drink and other bad habits which were
previously quite foreign to his nature.

The only case returned as vertigo will be seen in the table to figure
amongst the parietal injuries. This was a case following a shell-wound
of the left parietal area causing an apparently superficial scalp-wound
about 2 in. long in front of the anterior vertical line of Reid. On
examination, however, there were definite signs of a right-sided paresis.
There was probably some cortical or meningeal haemorrhage in this
case therefore. He complained mostly of dizziness, which came on
suddenly, and had on one or two occasions caused him to fall but not
to lose consciousness. The ground seemed to give way under him in
these attacks. He also was found to have some deafness in the left
ear, which on examination revealed no abnormality further than some
loss of polish of the left membrana tympani. The parietal injuries also
include the only case which was returned as psychasthenia. This took
the form of a syphilophobia which developed some months after a
bullet-wound of the posterior part of the left parietal region, which
was of the superficial character.

Of the two cases of organic dementia one was after a parietal injury.
This was the case of a man who had an old depression in his right
parietal bone corresponding to the circular opening in the skull. His
history-sheet showed that he had received this injury fifteen years
previously whilst serving in China, and it was interesting to note the
appearance seen in X-ray examination, suggesting that an effort had
been made by Nature to narrow the opening by a deposit of osseous
tissue at the circumference. This man re-enlisted at the outbreak of
war in August, 1914, and went to France, but at the end of twelve
months showed signs of mental deterioration, which rapidly progressed
into a state of marked dementia with childishness and gross memory
defect.

It was in these gross lesions of the parietal region that hemiplegias,
aphasias, apraxias and such conditions were met with.

Occipital Injuries.

There were a comparatively small number of wounds of the occipital
region, and only two in all were of a serious nature. The total number

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of cases in this group was 10, and of these 3 were right-sided, 2
left-sided, and the remaining 5 more or less in the middle line.
Amongst those with superficial injuries was one of the three cases of
epilepsy occurring in injuries of this kind. He was, however, of the
constitutional type of epilepsy, and had had a fit following an attack of
pneumonia when eight years old. Active service had evidently brought
out this latent tendency. After burial by shell also, prior to his head
injury, he had had another fit on account of which he bad been removed
from the front line. During the Somme advance, however, he was
returned to his unit and was wounded in the hand, and it was whilst
having his hand attended to at a “ first-aid post ” that the roof of the
dug-out fell in and he was struck on the back of the head by a fall of
timber. He was unconscious some hours and has since had fits at
intervals of about once a month.

The two cases whose injuries were of a more serious character were
both right-sided injuries and were both mentally melancholics. One
had a definite depression to be felt as the result of a blow on the head
from a girder of a bridge under which be was sheltering from shell-fire
after being wounded in the leg. He was returned to duty three months
later, but still complained of constant headaches and felt quite unable
to do his duty. He was subsequently admitted to hospital in a state
of acute melancholia, having made an attempt to end his misery by
strangulation with his puttees. X-ray examination revealed an evident
widening of the lambdoid suture, from which there was also seen a
small fissured fracture running forward which had evidently not been
previously recognised.

The other case was one in which there was extensive loss of bony
protection at the back of the skull as the result of a shrapnel wound
received in November, 1914. He bad since suffered from buzzing
noises in the head which made his life a misery. This man during
examination admitted that he had contemplated suicide on this account,
but no active steps towards this end had been made at the time he
came under my observation.

Temporal Injuries.

This group accounts for 13 cases, all of which were superficial,
except 3 which were cases of fracture, and in one of these metal
had penetrated the skull. They were equally divided between both
sides of the head, except for the last 3 cases, 2 of which were left¬
sided and one right.

Of the cases with superficial injury, which were of an apparently quite
insignificant character, the universal complaint of severe cephalalgia
was a conspicuous feature. In some cases it was so severe as to make
the patient giddy and cause him to sit down.

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1920.] BY RICHARD EAGER, M.D. 123

Of the more serious injuries one was a case of melancholia following
a penetrating wound of the left temple by a shell splinter. Fig. 2 is the
print from the X-ray plate of this case, which shows very well the
foreign body in the roof of the sphenoidal sinus. Here, again, pain
was the prominent symptom which had made the patient miserable.
It is also of importance to note that the patient had been informed in a
previous hospital that he had a piece of metal in his skull. This had
not helped the patient, for it was discovered by examination that this
patient had convinced himself that there must be a large piece of metal
pressing on the brain and that he was therefore doomed to lifelong
misery. With his troubles thus increased he considered himself better
dead, and he ultimately made active steps to hasten this end by
strangulation. When admitted under my observation he was in this
frame of mind, and it is interesting to note that by therapeutic conver¬
sations and re-education of his erroneous ideas a marked improvement
in his condition resulted, and in six months he expressed himself as
quite free from any feeling of depression and stated that the pain in his
head was considerably relieved. Twelve months after this man’s dis¬
charge from hospital he replied to my communication asking after his
condition and informed me that he was keeping well.

One of the other two cases had periods of amnesia following a
depressed fracture of the left temple. One amnesic period covered two
months, and was followed by other periods in which the patient seemed
confused and wandered about aimlessly. The death of a brother was
found to be an additional source of anxiety in this case. The remaining
case was one of maniacal excitement and alcoholic intemperance
following a fracture of the right temporal bone two years previously
This was a case clearly illustrating an instance of the refuge sought for
in alcohol as an attempt to gain relief from persistent pain in the head,
and the disastrous results which follow in cases with a previous head
injury.

Wounds of thb Mastoid Process.

There were 6 such injuries in this series of head injuries. Three
were superficial and 3 deep, and they were equally divided between
both sides of the skull.

The case I will quote is that of an acute hallucinatory state with
excitement in a man who had received a perforating bullet-wound.
The bullet had entered below the left orbit and found its exit at the
right mastoid process. The auditory nerve was completely severed,
and the antrum and middle ear thrown into one. A chronic otorrhoea
persisted up till eight months after the injury, when an acute condition
lit up again. He developed a temperature of 103‘8° F., and was for

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four weeks in a state of acute maniacal excitement with very vivid
hallucinations of sight. He convalesced satisfactorily in a further period
of two months.

The case of dementia praecox is the one already described.

Wounds of the Face.

The 5 remaining cases are included under this group. One was a
comparatively slight injury from a shell splinter below the right eye. He
was, however, at the same time blown up by the shell and subjected to
severe concussion. After admission to hospital he complained of very
severe pain in the head and behind the eyes. On examination he was
found to have a small nodule of metal opposite the infraorbital foramen,
and it was thought that there was a fracture of the infraorbital margin
of the orbit. The pain persisted, and two months later he developed
maniacal symptoms. These rapidly subsided, however, but the pain
remained. There was no optic neuritis or other signs of intracranial
pressure to account for this acute attack.

Another case was one in which hysterical deaf-mutism followed a
suggested side-to-side perforation over the region of the temporo-
maxillary articulation, and this man had such a miraculous escape that
I think for that reason alone there would be sufficient excuse for
recording his case. He was a sergeant in the Welsh Guards, and his
wounds were caused by shrapnel. One bullet appears to have passed
through the head from left to right just in front of the ears and above
the articulation of the inferior maxilla on either side. It lodged in the
wound of exit, from which it was removed. In transit it smashed the
plate of false teeth the patient was wearing, but did not apparently
damage the palate. A second bullet struck him over the centre of the
left clavicle killing his chum next to him, and a third bullet struck a
bullet-proof mirror which the patient was carrying in his left breast¬
pocket. It was in this way prevented from entering his chest. He
managed to crawl about fifty yards to the dressing-station and then lost
consciousness. About twenty-four hours later he came to himself again
and found he was in hospital at the base. He was from there evacuated
to England, and it was here about three months later that he lost his
speech and hearing, which was restored by appropriate therapeutic
methods within a few days of his admission to the psychiatric section.
This is one of only two cases with hysterical deaf-mutism met with
amongst these ioo cases, the other being amongst the parietal
injuries.

Another case of injury to the face was that of a man who, whilst in a
charge on the German lines, was wounded by a hand-grenade thrown
from a German trench. He was terribly mutilated and disfigured. In

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To illustrate paper by Dr. Richard Eager.

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1920.]

addition to losing bis eye he had a fracture of the upper jaw, the front
part of the alveolar margin of which seems to have been blown away.
The nasal bones were flattened out and apparently lost, and his
face was covered with scars. The lower lid on the right side was
everted and bound down to scar-tissue on his right cheek. Ten days
after his injury he became very depressed, and a few days later his
condition changed into one of acute maniacal excitement. This phase
lasted about a month, when he again became dull, depressed and
apathetic, and refused all nourishment except liquids. This condition
lasted about three months, when he steadily made improvement and
regained a normal mental state. This was maintained and enabled
him to be transferred to another hospital for a plastic operation.

The fourth case was wounded by a shell splinter on the left side of
his face whilst asleep. He had a granulating scar extending from the
externat angle of the left orbital process of the frontal downwards on to
his cheek and another scar on the bridge of his nose. X-ray examination
showed a fracture of the outer part of the floor of the left orbit. This
injury was followed by a period of amnesia lasting fifteen days, during
which he was somewhat dull and stupid in appearance, but otherwise
showed nothing particularly the matter with him.

The only remaining case to be described is that shown in Fig. 3.

This was a case of dementia following a shell-wound, the fragment
from which had penetrated the left orbit, destroying the left eye, and
lodged itself finally in the centrum ovale of the right hemisphere. It
had evidently severed the internal capsule in transit, for the patient had
a complete hemiplegia affecting the left arm and leg and left side of
the face. This man could give little information about himself, and
his memory was very seriously affected. He was extremely irritable,
continually asking for food and attention, and seemed quite unaware
of the fact that only a few minutes previously he had received both.
His left arm was in a state of contracture, but the leg was flaccid with
anaesthesia; extensor plantar reflex was present as well as ankle-clonus
and increased tendon-jerks. His face was flattened on the left side,
and the mouth drawn slightly to the right. He constantly cried out,
complaining of pain in the right side of the head, which he referred
mostly to the frontal region, and he was altogether in a most pitiable
condition.

Summary and Conclusions.

In summarising my observations on this series of head injuries I will
call attention to the following points:

Out of the 100 cases 49 had evidence of serious cranial injury, 14
had trephine openings in the skull, and 12 had metal still remaining in
the cranial cavity.

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Incidence. —From figures published up to date (9), the proportion of
total head injuries to total disabled works out at 4 per cent., and from
the same figures 75 per cent, is quoted as the proportion of insane.
As, however, in my experience the proportion of head injuries which
occurs amongst the insane admissions in a large hospital for receiving
mental patients is only 2 per cent., it may be assumed that the pro¬
portion of head-injury cases that subsequently become insane is some¬
where about 775 per cent., which is not far removed from the ratio of
insane to the population in ordinary civil life. The small number of
bead injuries, therefore, in which mental symptoms have developed is,
I think, a point worthy of notice, and must lead us to alter our pre-war
conceptions with regard to this subject.

Epilepsy. —Here again I must draw attention to the relatively small
number of cases met with. Only 15 per cent, were epileptics, and all
these occurred amongst cases with serious cranial injury except 4. Of
the latter one was known to have had fits as a child.

The cases of epilepsy therefore vastly predominate in cases where
there has been some gross cranial injury, and especially so where the
injury was of the nature of a penetrating wound, for all except one of
the 11 cases had wounds of this nature. In 4 instances metal still
remained in the skull, and one case had an abscess of the frontal lobe.
Eight cases had been trephined. The period of interval between the
head injury and the first fit varied from a few hours to years, but in the
vast majority of cases was about five months after the injury. In only
one case did the fits seem to start directly after the injury, recurring at
intervals of every ten days. The intervals between successive fits were
irregular. In some cases they were daily, in others weekly or monthly.
There were two cases of status epilepticus. One occurred twelve months
alter the injury; the other case had three bouts of this condition at
intervals of five, eight, and ten months after his head injury, and he died
in the last attack after a succession of eighty-six fits extending over the
last four days of his life. The almost universal occurrence of these
epileptic cases after injuries of the parietal region of the skull has
been already pointed out. Nearly all cases with large osseous defects
were epileptics, and here I wish to draw attention to the warning given
to operating surgeons by Col. L. B. Rawling (10), that the smaller the
osseous defect left after operation the less dangerous from the point
of view of epilepsy.

Amnesia. —Of the 12 cases showing this condition as the pre¬
dominant symptom 6 were frontal injuries, and 4 of these superficial.
The other 6 cases were fairly evenly distributed over the other areas.
No relation seems to exist between the amnesia and the severity of the
injury. Half of the cases had superficial injuries; on the other hand
there were instances amongst these cases of fracture of the parietal

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1920.]

temporal and malar bones, and one case had a piece of metal in the
great longitudinal fissure. There can be little doubt that to the medical
man without any special knowledge or training in such conditions these
cases of amnesia present considerable difficulty. Especially when these
attacks occur with “ fugues ” in men under active service conditions, it
is not always a simple matter to distinguish them from an avoidance
of duty which is purposive on the patient’s part. Where, however, in
addition, the man has had a definite head injury, I think a little more
benefit of the doubt might at all events be given in his favour. Amongst
my series of cases were instances in which N.C.Os. had been reduced
to the ranks for “absence without leave” where it had not been
recognised till long afterwards that these periods of absence were
really amnesic fugues following on a head injury. Any effort to obtain
justice for these men at this late stage of the proceedings was doomed
to failure.

Acute hallucinatory states .—There were 8 cases of this nature, and
in 4 of these there was a definite history of sepsis. Such a case has
been described amongst the injuries of the mastoid region.

Mental deficiency. —It has been already stated that the 3 cases
returned as such were cases in which the head injury had not apparently
produced any fresh symptoms, but seemed to have increased the
severity of those already existing, and so reduced a case of this kind to
a lower level of intelligence. In addition to these cases there were,
however, 12 other cases investigation of which elicited the fact that
mental deficiency was an underlying condition, existed prior to enlist¬
ment, and had been superimposed by other symptoms following the
head injury. Apart from cases of head injury, however, this was quite
a common feature in the war psychoses generally, as has been pointed
out by Major Stanford Read (11) whilst medical officer in charge of
the Mental Clearing Hospital at Netley. In the 12 cases mentioned
above the superimposed symptoms were of wide variety. Two cases
developed epilepsy, and in both cases the injury was a parietal one,
1 became melancholic following a fracture of the frontal, 4 exhibited
states of mental confusion and hallucinosis, 2 of which followed fractures
and 2 superficial injuries. Two were of the amnesic variety following
superficial injuries of the temporal region, 2 were of the mentally
unstable type of individual, and 1 was a case in which the moral side
seemed to have been the one chiefly affected.

Heredity and previous attacks. —Whereas there were 4 cases in which
there was a history of previous confinement in an asylum, there were, on
the other hand, 3 cases with over eleven years’ continuous service in the
army with good character. Of the former also it should be mentioned
that 1 case had a kick in the forehead from a horse, causing a fracture
of the frontal bone, prior to his admission to the asylum. An inquiry

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into the family history of the remaining cases brought forth no evidence
of conspicuous neurotic tendency, and therefore it seems difficult to
support any argument that hereditary predisposition is a factor of any
great importance in these cases.

Alcoholic intemperance .—Out of 14 cases in which it seemed that
alcohol was an associated factor, further investigation showed that in
8 of these cases the intemperance had developed since the head injury. I
am of the opinion that the tolerance to alcohol is considerably diminished
by head injury, and it is probable that the injury brings about a loss of
power of inhibition in this respect.

Other symptoms .—The commonest subjective symptoms were a feeling
of restlessness and irritability, a lack of confidence, and an inability on
the part of the patient to concentrate his attention on anything. One
case expressed himself as follows: “ Before my head injury I used to
fear neither God, man, or the Devil, but now I have a feeling that
something stops me doing things I used to do.” This feeling seemed
to be practically universally present in greater or less degree, but not
more conspicuously so in injury of any one area more than another.

Pain was also a fairly constant symptom varying in intensity, though
generally severe in character, and usually, but not universally, referred
to the site of injury. Noise seems to make the pain worse, and it is
invariably aggravated by stooping. The common occurrence of head¬
ache, which was so often of a persistent nature, no doubt accounts for
the high percentage (22 per cent.) of cases of the melancholic type.
In many such cases one not infrequently found that the pain had been
so severe that the patient had taken on duties involving exceptional
risks with the sole object that by so doing he would find a final release
to his sufferings. The refuge sought for in alcohol as a relief to these
symptoms has also been referred to, and needs no further emphasis
here.C') Pain was comparatively rarely compj^ined of in cases where
there had been a trephine operation, except as a premonitory symptom
to “ fits.” The constant unbearable pain complained of in the cases
with apparently superficial injuries was, however, not met with in those
trephined. In the case already described amongst the occipital injuries
in which there was a large deficiency of bony protection at the back
of the skull pain was not complained of. Here it seems that the
hallucinations were responsible for the melancholic state. It seems,
therefore, clear that pain associated with apparently superficial injuries
is to be regarded as of some importance, and the number of cases who
had been returned to duty still complaining of pain shows that this is
not sufficiently often regarded as such in these cases. A case in point
received a superficial wound of the skull on October 21st, 1916. He
managed to land in hospital in England, but was eventually discharged
to his depot still complaining of pain. He could gain no relief for

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this, and a month later he volunteered to return to France. His wish
was acceded to, and four months later he was sent back to England
again as unfit to perform his duties. He was in hospital two months
when he was again discharged as fit for duty, but still complaining of
the pain. Two months later he was admitted to hospital again with a
cut-throat wound. Another patient with a similar history and the same
intention conceived the somewhat unique idea of achieving this end by
completely severing his right tendo-Achillis. Other cases could be
mentioned, but I think these are sufficient to emphasise the importance
of pain in the head as a symptom in cases of head injury, even though
this seems to be of a superficial character.

X-ray examination .—No relationship can be found to constantly
exist between the apparent injury or superficial scar and the actual
damage to the skull, and therefore I feel that X-ray examinations should
be more universally made in the cases in which the head injury appears
to be of a superficial nature. Some do not seem to realise the importance
of this, whilst others definitely discourage the use of X-ray examination
in cases of the psychoneurotic type on the ground that the information
so obtained is sometimes conveyed to the patient, on whom it has a
detrimental influence. (12) Such a case, it must be admitted, was met
with amongst this series of head injuries and is shown in Fig. 2.
But with the provisio that information obtained by this method of
examination will not be unnecessarily handed on to the patient I
would urge its more general application, for there were many cases
where gross injury to the skull was found in which X-ray examination
had been neglected prior to admission to the psychiatric section. One
man had been blown up by shell and was unconscious when found.
His mouth was then drawn slightly to the left side, but this soon
returned to normal, and his chief complaint was of thumping pains in
the head. Three months later he developed epileptic fits. There was
no evidence of head injury to inspection or palpation in this case
when he came under my observation, and had it not been for the
information gained by X-ray examination an extensive fracture would
have escaped detection, and little credit would have been given to the
patient for his head injury.

Conclusions .—In considering these cases of head injury in detail one
is struck by the impossibility of grouping them in any way which
would show any relationship between the mental symptoms presented
and the site of the cranial injury. Hollander, in his book published in
1910(13), described a whole host of cases of head injury, and argues
that injury of the frontal region produces loss of self-control going on
to dementia, injuries of the parietal region produce symptoms of melan¬
cholia, injury of the temporal region mania, and that emotionalism and
loss of inhibitory power over the muscles that express the affective state

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follow injuries of the occiput. But I am unable to support his findings.
On the other hand, it seems clear that epilepsy is most commonly met
with where there has been gross damage to the walls of the skull, and
especially so when in the parietal region. Pain is an important symptom
almost universally present even in quite trivial injuries, especially so
when such occur in the temporal region, and I wish here to lay emphasis
on the necessity for more sympathetic consideration to be given to it
than appears to be done by many medical officers dealing with such
cases in surgical wards. Further, it is deplorable to observe how the
attitude of the average physician or surgeon completely changes towards
his patient who presents any symptoms which cannot readily be accounted
for by physical causes. He at once loses all interest in the patient,
which I venture to suggest is instantly recognised by the patient and
only adds to the distress of the latter, with often fatal consequences. A
definite irritability of temper and loss of power of concentration was
an almost universal accompaniment in these cases of head injury,
without any indication that it was more pronounced or more commonly
present in injuries of any one special region of the head. It seems, as
MacCurdy(i4) says, that in many cases in which there have been
gradually accumulating difficulties not sufficient to incapacitate the
patient there is a sudden increase of symptoms following even a mild
concussion, and that in the low state of mental tension consequent on
cerebral injury higher functions are in abeyance, and the unconscious
and instinctive tendencies readily gain the upper hand. A great
number of cases on analysis showed the existence of mental conflict
of repressed complexes, as is so ably described by Hart(i5), and treat¬
ment on psycho-therapeutic lines in most cases speedily relieved the
mental symptoms, and in not a few instances the headaches also seemed
to be diminished in severity. It has been pointed out by Farrar(i6),
Turner(17) and Hart(18), and is now generally accepted, that the
“ traumatic neuroses ” in which every nervous phenomenon including
dissociated states of consciousness are exhibited are “ functional dis¬
orders” brought about by the psychic and not the physical shock.
So it seems that in these cases of “traumatic psychoses” with head
injury the mental symptoms were referable to psychic rather than
physical causes.

I am much indebted to Capt. W. H. Hooton, Radiologist to the
Lord Derby War Hospital, for much time and trouble spent in furnishing
me with X-ray reports and photographs.

References.

(1) The Journal of the Royal Army Medical Corps, September, 1916
and 1918.

(2) The British Journal of Surgery, vol. ii, July, 1915, to April, 1916.

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(3) Purves Stewart.— The Diagnosis of Nervous Disorders.

(4) Capt. H. J. Norman.— The Review of Neurology and Psychiatry,
August-September, 1917.

(5) Halliburton's Handbook of Physiology : “ Functions of the
Cerebrum.”

(6) Oppenheim's Text-Book on Nervous Diseases , vol. ii.

(7) The Daily Review of the Foreign Press, April 1st, 1918.

(8) Roussey.— The Psycho-neuroses of the War.

(9) Parliamentary Report, May 28th, 1918.

(10) Meeting of the Medical Society, London, November 15th, 19x5.

(11) “A Survey of War Neuropsychiatry,” The American Journal
of Mental Hygiene.

S i 2) Joum. Ment. Sci., October, 1918, p. 404.

13) Bernard Hollander.— The Mental Symptoms of Brain Disease.
14) J. T. MacCurdy.— War Neuroses, Cambridge University Press.

(15) Bernard Hart.— The Psychology of Insanity.

(16) C. B. Farrar.— American Journal of Insanity, July, 1917.

(17) “The Bradshaw Lecture on Neuroses and Psychoses of War,
Lancet, November 9th, 1918.

(18) Bernard Hart.—“The Modern Treatment of Mental and
Nervous Disorders,” Manchester University Lectures, No. xxi.

(’) Paper read at the Autumn Meeting of the South*Western Division of the
Medico-Psychological Association, University College, Bristol, October 24th, 1019.
(*) Since writing these views, the author is glad to find that Stanford Read in
Military Psychiatry in Peace and War, published by Lewis & Co., expresses
somewhat similar views. This book is highly commended.

Some Points of Interest in connection with the Psychoneuroses of
War.(') By George Rutherford Jeffrey, M.D., F.R.C.P.E.,
F.R.S.E., Medical Superintendent, Bootham Park, York.

Upon the outbreak of the recent war, most of us, after experiencing
a transitory phase of almost breathless suspense, passed, I think, into a
state of apprehensive ignorance. Inwardly we had a feeling of un¬
certainty, but had indeed little idea of what the war would unfold; still
less did we realise that we would have to face and counteract such
countless schemes and devices which had been prepared for our
destruction. As time went on we gradually found that we were almost
instinctively prepared, or, at least, in a position to react and protect
ourselves. Such a state of affairs was not an experience confined to
any one branch of the services: the medical department experienced
the same. Very soon this department recognised that difficult times
were ahead, and that they would have to treat, not only the ordinary
battle casualties, but many other conditions apart from ordinary
surgical and medical cases. So the various specialties of medicine
were affected, and none more so than that which dealt with affections
LXVI. IO

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implicating the nervous system. Soon the authorities had to give
special attention, not only to the care and treatment of the many cases
of undeniable mental disease, but also to a greater problem, namely,
the large group of conditions comprising the psychoneuroses. There
began to appear endless literature on the subject, which is still forth¬
coming. I mention this fact principally in order that it may be realised
how difficult it is even to attempt a brief risumi of this important
branch of medicine, comprising the psychoses, neuroses and psycho¬
neuroses. In addition I do not feel justified in expressing definite
opinions, generally speaking, largely on account of the limitations of my
military experience. I had not the opportunity of seeing such con¬
ditions in the front lines, nor at the large base hospitals abroad, for,
during nearly the whole of my time in the army I was stationed at a
military hospital in this country. In this hospital, however, I had the
opportunity of seeing the more advanced cases of shell-shock, neuras¬
thenia and allied states. I shall therefore confine my remarks chiefly
to these conditions.

I say “allied states,” for in considering the question of shell-shock we
cannot eliminate neurasthenia, and even psychasthenia and hysteria.
Instead of using the term “shell-shock,” I would prefer to call it “nervous
shock.” It was perhaps unfortunate that such a term as shell-shock was
generally adopted. Although its precise meaning is vague, the term is
used to include a vast number of cases presenting obscure symptoms,
and is indeed a useful basket into which can be thrown the vast number
of cases which present mental symptoms without any apparent wound
or injury. In this respect the term answered admirably; not only so,
but it had about it in the eyes of the public a plausible ring with an air
of scientific accuracy. To the sufferer himself it appealed, and it is, I
think, in this respect that the term is open to criticism. I have met
with many men who, when told that they were neurasthenic, became
bitterly resentful, and asserted that neurasthenia was the very last thing
they were suffering from, and that their condition was one of shell-shock.
To a certain type of neurasthenic the term “ shell-shock ” appealed. It
savoured of the noise and din of battle, screeching shells and great
explosions, causing, not a giving way to pent-up emotion, but a collapse
of the nervous system from actual wound. Still, we must remember that
never before in history has the human frame been exposed to such ordeals
and strains, and if in civil life shock is capable of producing a nervous
breakdown, all the more would it do so under the truly appalling trials
our men had to face. I think I might at once refer to the belief held
by many people, medical men as well as laymen, that this condition—
shock or neurasthenia—was but another name for what is vulgarly
known as “ funk.” Although in some cases we undoubtedly had to
raise the question of “ funk ” or malingering, I would point out in con-

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tradiction to this belief (i) that often the worst cases occurred in those
whose pre-war as well as actual war history could stand the most careful
scrutiny, and establish beyond the slightest doubt that those in question
had been normally men of steady and fearless character, (a) That in
a very large number of these cases we met with men who, although
undoubtedly neurasthenic and far from fit for duty, pleaded to be sent
back to tbe fighting line. (3) That precisely the same symptoms
appeared in the seasoned soldier as well as in the soldier with little battle
experience. (4) I have known cases to be returned more than once to
duty, in entire concurrence with the wishes of the individual, only to
break down again.

Regarding the setiological factors in the causation of this condition,
in previous campaigns the occurrence of mental disorders was by no
means rare, and the study of mental diseases was no new branch of
medicine; and yet, at the outbreak of the great war, the attitude of a
large section of the army medical department was similar to that of the
general public, who thought, and perhaps naturally, that those who were
afflicted with mental disease were but useless burdens, little deserving of
sympathy. These unfortunate invalids, in many cases the pick of our man¬
hood, who, after the dreadful trials, privations and suffering of the first few
months of the war had broken down, mentally and nervously, received,
I fear, but little sympathy. Such a state of affairs was bound to exist at
first, and amidst the bustle and burdens of the task that lay before the
authorities in making provision for the wounded it was only natural
that such conditions received only moderate attention.

As time went on, however, it became apparent that nervous and
mental diseases were going to claim a considerable number of cases,
and, this being so, provision had to be made not only for recognising
such states, but for treating them skilfully.

In support of these remarks, I recollect in the early days of the war
having seen discharged soldiers who, having broken down on service,
were finally committed to an asylum with a definite mental diagnosis.
I can recall the case of a young man who came under my care as
a case of dementia prsecox, an incurable and, at times, supposed to
be a dangerous lunatic, but his was a case of adolescent neurasthenia
—at that time perhaps a somewhat rare condition; under proper treat¬
ment he eventually got quite well. Time showed that these were the
kind of cases which were going to be very numerous, and would form
an important group of cases requiring competent and skilled treatment.

Did the war produce any new or definite psychosis is a question
which is constantly being asked, and concerning which opinions greatly
differ.

Some assert that, although the war undoubtedly produced many cases
of mental disease, it provided nothing new. With this opinion others

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are inclined to disagree, and although they admit that perhaps there
was produced no new actual mental disease, there occurred many mental
types the origin and development of which were different from those of
peace time, and especially did we meet with a great number of so-called
borderland cases. Let me sketch what happened. The country, after
a period of suspense, was plunged into war: there was a sudden depar¬
ture from the ordinary existence, acute suspense and excitement
prevailed, and then there followed a chain of circumstances hitherto
quite foreign to most, and of such a kind as was bound to exert an
influence on the nervous system of even the strongest man. A wave of
uncertainty swept over the nation ; the leap into the dark unknown, the
noise and the bustle, the breaking up of homes, the feeling of possible
separation and death, were but a few circumstances which were bound
to exert some influence on the emotions and feelings of the strongest.
Under these preliminary adverse circumstances many broke down—
those who were mentally weak or unevenly balanced, and those of
emotional temperament. But it did not end there; our men were to
face more terrible circumstances and ordeals which undoubtedly pro¬
duced and accentuated feeling of pent-up emotion ; then came the actual
physical fatigue of marching, and the many hardships, alarms and nerve-
racking sights. These were common to all combatants, and un¬
doubtedly here again many broke down, and others who did not
actually break down became mentally weakened—they became, in
other words, suitable persons for future collapse, if not indeed potential
neurasthenics. At first it would appear as if almost all should break
down, but this was far from being so; nervous systems adapted them¬
selves in the most extraordinary way ; not only so, but the inherent
stamina of the race showed itself. Thus there were in the first instance
the so-called weaklings who broke down almost at once, even during
training. Then came the second group: those usually with a poor
heredity, who had been weakened mentally by their initial experiences,
and broke down whenever they approached the battle zone. I can recall
many such cases. One case was that of an officer, never very
robust mentally, who told me that everything in connection with his
military training had worried him. On his way to the front the train in
which he travelled was bombed : he almost at once broke down, had a
so-called hysterical fit, was evacuated to the base, and admitted to
hospital in England suffering from neurasthenia. The third group
comprised those soldiers, in many cases regulars and the pick of the
army, who had experienced considerable active service, but who
eventually broke down and became nervous wrecks. I can illustrate this
group by the case of a young officer—a regular—who went with the first
draft of men to France, and saw a great deal of service for three years
before he broke down. He was strong and muscular, and a great

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athlete. He was present at the Mons retreat and marched for almost
seventeen hours at the head of his company, carrying, not only his own
kit, but that of another. On halting for the night he took sentry duty
himself as he considered he was the fittest man in the company. In
the morning he led a counter-attack, and was but little the worse for it.
He fought on for nearly three years, full of pluck, enthusiasm and
endurance. One day he was making observations from the inside of a
tall chimney with his sergeant A shell struck the chimney, making a
large hole and carrying away the climbing supports. His sergeant fell
to the ground and was killed. He had to descend, and yet the supports
were gone. Without thinking he released his grip, and trusted that he
would catch on to a support further down the chimney. This he
accomplished, perhaps owing to the fact that he was a great gymnast.
Immediately after reaching the ground the chimney fell, and he was
buried in some of the iibris . When rescued he was dazed and speech¬
less, and finally was admitted to hospital suffering from a severe attack
of neurasthenia. Such a case illustrates most forcibly that even the
strongest may in time collapse, and the wonder is that more did not
break down under such constant and terrible trials.

I will now briefly detail the aetiological points which appear to be
common to psychoneuroses.

Predisposing Causes.

(1) A neuropathic constitution is a potent factor, and may be
hereditary or acquired; I prefer, however, to call it “ the emotional
temperament,” a term which I first used in a paper on “ The Cause
of Neuropathic States.”(*) Those who inherited this diathesis had not
much chance, and furnished most of the cases who broke down almost
at once. Then the condition may be acquired. I have already shown
that even the strongest man may become so much weakened that he
readily, under adverse circumstances, breaks down. The neuropathic
constitution does not remain latent, but shows itself under circum¬
stances when the emotional reactions are brought into play, and may
reveal itself by an exaggerated expression of the mental and physical
reactions of the emotions.

(2) In fatigue, mental or physical, we have another factor that is of
paramount importance. By its’ depressant action it involves undoubt¬
edly a great expenditure of energy and produces a general weakening
of mental tone.

(3) Effects produced by temporary shortage of food and the intoxi¬
cations.

(4) An aetiological factor also of importance, I think, in producing a
lowered, or, at least, changed mental state, is that to be found in the

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mental effect produced by distaste or disappointment in the person
suddenly passing from an important civil position to the position of an
ordinary soldier.

Exciting Causes.

(1) In direct concussion, no matter whether the individual has been
thrown to the ground, against the wall of a dug-out, or actually struck
on the skull by any object, there is a shaking of the nervous system.
Although this may cause a psychopathic disorder, it more readily
produces an organic lesion. Indirect concussion, on the other hand,
produces almost exclusively neuropathic symptoms.

(2) Along with concussion we must consider local trauma which causes
motor and sensory changes in some part of the body. It produces first
of all an emotional state, and then, under cover of this, the idea of some
disorder is suggested, e. g., a severe shock to a limb may produce a
temporary paresis. In the normal individual this rapidly passes off,
but in the neuropath the idea of immobility becomes fixed by auto¬
suggestion.

(3) There is the share taken by emotion and suggestion in
psychoneuropathic conditions. Regarding this many questions require
an answer, e.g., To what extent is emotion responsible for the establish¬
ment of the symptoms in the psychoneuroses ? How far does emotion
extend? What is emotionalism? What are its physical and mental
reactions, etc ? Dejerine and Gauckler in their book on the psycho¬
neuroses say that emotion may be of external or internal origin. First
of all as regards emotional strain of external origin, a person may
receive some great shock—physical or mental—without any warning.
The shock may come in the form of sudden and great joy. In these,
the common factor is that the person passes from one situation into
another for which he is quite unprepared. Between great shocks and
slight emotional stimuli there are many grades.

Emotional stimuli may be of internal origin, e.g., the memory of some
previous shock, the feelings of impending grief or catastrophe. Gene¬
rally speaking emotion is a reaction of the personality, and, as an
immediate result, may completely overthrow the equilibrium of the
subject. As a rule the psychic disturbance is passing, followed by a
return to normal mentality. But this may not be so. The primary
effects of the emotional stimuli may remain until the appearance of
the later phenomena, constituting by the symptoms they produce the
majority of the functional troubles.

But the person who experiences one emotional shock does not become
neurasthenic unless he has been unable to free himself from the
memory of the emotion, which continues to return again and again.

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He cannot adapt himself; his mental energy begins to fail; the will
becomes powerless and he is over-ruled by preoccupation. In other
words the neurasthenic state follows his inability to adapt himself to
continued emotional stimuli.

The two chief exciting causes of a neuropathic disorder are the
revival of an emotion, and secondly auto-suggestion created by emotion.
It is known, for example, as Roussy and Thermitte point out in their
book on the psycho-neurosis of war, that shock to a limb caused by
a projectile of high velocity may immediaetly produce a transient but
complete motor or sensory paralysis, but which in the normal individual
rapidly disappears. It is quite another matter in the neuropathic, in
whom this impotence becomes fixed and made stable by the action of
auto-suggestion.

The Symptoms.

I will now briefly indicate the symptoms of the condition, and for
convenience shall divide them into early and late. The early symptoms
hardly concern us except inasmuch as there is a tendency for them to
continue—perhaps in a more chronic or more intensified form—in the
later stage of the illness. A common history is as follows: Explosion
of shell; the patient is buried completely or partially, and rendered
unconscious. On regaining consciousness some of the following sym¬
ptoms may be noticed: intense headache, nervousness, tremors,
epileptiform attacks, choreiform movements, motor disorders, mono¬
plegia, hemiplegia, paraplegia, disorders of gait, disorders of hearing
and of speech, contractures, and, in addition, pronounced general
symptoms of early neurasthenia, as, e.g., insomnia, loss of initiative and
will-power, lack of power of concentration, altered heart action, etc.
Later, there may occur many of the symptoms of the early stages,
perhaps in a more intensified form, and, in addition—and this is a
point of importance—we have a prominence of psychical disorders.
They are the psychoneurotic sequelae of the most persistent symptoms
which remain and which we are called upon to treat.

The most important are:

(1) Headache.

(2) Loss of memory and lack of power of concentration.

(3) Disordered action of the heart.

(4) General nervousness.

(5) Disorders of special sensation.

(6) Insomnia.

(7) Persistent and terrifying dreams.

(8) Exaggerated tendon reflexes, etc.

Two cases are related which bring out vividly many important points
in connection with symptoms.

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The first is that of an officer who had seen considerable service.
During a very heavy bombardment a shell struck the roof of the
dug-out where he was with several other officers. The other occupants
were killed, and he himself was partially buried, and was firmly fixed to
the ground by a beam of wood across his shoulder. Eventually he lost
consciousness, and remembered nothing until he awoke in a casualty
clearing station, and from which he was sent to the base. He was
then intensely nervous, suffered from headaches and loss of memory,
insomnia, battle dreams and tremors, and his left arm was firmly
contracted with the shoulder raised. There was general bruising of the
shoulder and arm, but nothing more. He was evacuated to England.
After a time he improved generally: practically all the symptoms of
neurasthenia had disappeared, but there remained the contracture. I
administered chloroform and made certain that there was no compli¬
cation from fracture, although there were naturally some adhesions at
the elbow, and which I broke down. Gradually as he came out of the
anaesthetic his arm began to contract, and when completely conscious
the contracture was as marked as before. In the course of my talks
with him I convinced him that it was only a functional condition, and
that he would get quite well. Moreover I told him that I would give
him some massage, but that on a definite day—three weeks was the
time that I mentioned—his arm would be quite well. At first there was
no change in the contracture under treatment, until the three weeks had
almost elapsed; then suddenly it improved—he got again complete use
of his arm, gained strength in every way, and, at his own request, was
returned to duty.

The second case shows very extraordinary symptoms, both mental
and physical. This was a case which I studied very carefully, and
might be described as one of traumatic neurasthenia. Along with my
notes of the case it is fully quoted in Lt.-Col. Marr’s book on the
Psychoses of War , and briefly the facts are as follows: The patient was
an officer in the Royal Air Force, and during a hostile raid over London
was caught in the fire of his own barrage and crashed to the ground—a
distance of 10,000 feet He was unconscious for three weeks, at the
end of which time he was given leave. He was recalled and sent to a
bombing school, but his memory for the next ten weeks was a com¬
plete blank. After some trouble with the military authorities he was
“ boarded ” and given leave, towards the end of which he got married,
but, not only did he not remember the marriage ceremony, the place or
the church, but he did not marry the girl to whom he was already
engaged. He recollected having many strange ideas, e. g., he thought
that he was a cuckoo or a cow, and these he would imitate He was
finally admitted again to Hospital, and, on admission, was intensely
confused and emotional, with complete loss of memory.

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The nervous system showed the following symptoms:

(1) Giddiness in changing his position or raising himself in bed.

(2) Inability to stand with his eyes shut, a tendency to fall to

the left, and inability to walk on a straight line.

(3) Inco-ordination of the upper limbs.

(4) Defective sense of smell—first cranial nerve.

(5) Diplopia of right eye; paralysis of right external rectus

muscle—sixth nerve.

(6) Twitching of right upper and lower eyelids (third nerve).

(7) Squint; limitation of right lateral visual field; rotary, and

at times, lateral nystagmus.

(8) Deafness in left ear; bone-conduction nil; eighth nerve.

(9) Superficial and deep reflexes exaggerated.

(10) Ankle and knee clonus, but no Babinski.

These symptoms undoubtedly suggested an organic lesion, but they
were due to toxic neurasthenia. With rest and general treatment he
improved, although his symptoms varied from day to day. Then one
night he had a very vivid dream—that he was falling to the ground in a
bright red flaming aeroplane. When I visited him in the morning he
told me of this and said that his memory had returned, and he was able
to relate in detail much of what had happened. Gradually he improved,
and he was eventually discharged and sent to his home. This case was
of fascinating interest, and much time could be taken up in discussing it
in detail, but I am convinced it was a traumatic psychosis with a toxic
neurasthenia, and it is certainly interesting as illustrating the extra¬
ordinary complexity of symptoms in such a condition.

Treatment.

The treatment of shell-shock, or rather of the sequelae of this
condition, is intensely difficult. Unlike many diseases, the many
obscure symptoms which are present cannot be lessened or helped by
actual drugs. And yet there is much that can be done. Nothing,
however, can be done unless we understand the condition with which
we are dealing, and it is perhaps this feeling of ignorance that is so
much against us—it causes hesitation and uncertainty, which is very
readily recognised by the patient. With the physician there must—
outwardly at least—be no room for doubt: he must be ready to attempt
to explain to his patient, and in as convincing a way as possible, that he
is the master of the disease, and in the treatment of such conditions
this is half the battle. I shall not deal with general therapeutic
measures: it is important that these should receive careful attention. It is
important also that the physician should deal most tactfully with any
bodily ailment from which the patient may suffer, remembering always
that carelessness in the recognition of this may be the means of losing

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the patient’s confidence, whilst undue attention to the ailment may be
the means of creating fresh and false impressions of its significance.
But there are certain therapeutic measures which perhaps may appear
trifling, but which are, in reality, of the greatest importance, and to
these I shall refer in more detail.

Sympathy .—The importance of sympathy cannot be over-estimated.
There must be shown towards the patient all possible sympathy, remem¬
bering always that to him the illness is painfully real. In the first few
interviews much will have been accomplished if the patient has
been made to realise that the physician feels for him in his suffering; and
never by word or look should he be given cause to infer otherwise. But,
with the sympathy, there must be firmness—that is to say, although
sympathy must be shown, he must be induced to face his illness in a
manly way, and impressed that even the most persistent of symptoms
will eventually disappear. Sympathy must be real, for unless the
sympathiser has an appreciation of the patient’s condition and can look at
it as he does, he cannot really feel with the sufferer. True, manly and
firm sympathy is, 1 hold, the greatest therapeutic measure that we have
in such cases. Its therapeutic action, however, is not like that of a
drug; it is more—it is the action on sensitive nerve-cells. It plays upon
the emotions, creating in the sufferer a feeling of trust, and this has ita
effect, for it almost forces him to unburden the “ subconscious ”: it gives
the physician a chance of getting well acquainted with the contents of
mind; it enables him to link up circumstances, and is the keystone to
all further treatment. I cannot lay too much stress on the importance
of doing everything that is in one’s power to obtain the patient’s con¬
fidence at the beginning. It has often been said that it is bad for the
patient to make him talk about himself, or his worries. But, I ask, How
can a physician rid the patient of his troubles without first of all
discovering what they are, and then discussing them with the patient l
Without getting at the root of the patient’s trouble, it is quite futile to
tell him to cheer up, stop worrying, go and work, etc.

Secondly, isolation is of importance, and should be in the first in¬
stance always attempted. It removes the patient from many circum¬
stances which would be harmful. But occasionally it does not succeed,
and should never be persisted in when it causes worry, undue
annoyance, or a tendency to depression. It is also of importance to
explain to the patient why isolation is necessary—namely, to remove a
sensitive nervous system as far as possible from the ordinary worrying,
although perhaps trivial circumstances of life. Still, speaking generally,
isolation—more or less severe—is usually helpful.

Hypnosis and suggestion. —The efficacy of this method of treatment
has, I think, been established beyond doubt, but it is a form of treat¬
ment which must be used with great caution; it cannot be employed in

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a haphazard way, but must always be used with a definite object in view,
and with a full knowledge of what result is to be looked for. With
reference to this method of treatment there is nothing obscure.
Suggestion is the keynote of successful treatment, and, as I have already
pointed out, the soil upon which it is to be placed can first of all be
prepared by sympathy. Thus, to cure a mental state, we are not going
to employ drugs, but are going to attack this mental state by mental
methods. It is, in fact, the influence of one mind upon another.

Hypnosis has been used in several ways. It was extensively employed
in the acute cases to cure such conditions as mutism, etc., and in which
it answered admirably. It bas been used alone to calm the patient
and bring about natural sleep. It bas been employed to recall past
memories, make the patient live through his experiences again, and get
at the early points in connection with the illness. And it has been
employed as an aid to suggestion in patients who are so much obsessed
by their own beliefs that the physician cannot in any way influence them
—acting by breaking down resistance, and preparing the soil for sugges¬
tion. This method of treatment I have employed with considerable
amount of success, and, although I never had the opportunity of using
it in the early cases, I have used it in many others, and have been able
successfully to attack the more chronic conditions like paralysis and
contractures—the most difficult of all to treat. As a method of inducing
sleep hypnosis is most valuable; as an aid to suggestion its useful¬
ness is undeniable; and further, it has, I am certain, a distinct place in
the therapeutics of mental diseases when used with skill, discretion and
care. It has been said that it has no lasting effects, and is but a
passing stimulus, but with this I do not wholly agree. The treatment
must be persevered with and continued, and undoubtedly it can help in
the restoration to health of the long-standing and persistent cases of
shell-shock in a manner quite unrivalled by other means.

There is but one thing more that I would mention in detail, and that
is the persistent battle dreams, which are often so vivid and so difficult
to get rid of. Most people would say to the patient: “Don’t think
about your experiences when you go to bed.” Well, this is entirely
wrong, for the impressions become buried in the subconscious mind,
and then come into the conscious during sleep. The patient should be
told that, after he is in bed, be should carefully write out and read over
the dream that has troubled him, and you will find that if this is done a
few times the dream will disappear altogether. This certainly is my
experience.

This does not, however, exhaust our methods of treatment; we have
still one other which must be mentioned, although it is but an accumu¬
lation, a gathering together of all our means of treatment, and making a
combined attack on the mental state, the mental life, past and present, of

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the individual, using what means we can to get right to the bottom of
an almost unfathomable condition, building up and pulling down,
cleaning out and renovating, so that everything is cross-examined, every
symptom correlated with its casual facts. And such a method of
treatment we call “ psycho-analysis.” It is, at least, my conception of
psycho-analysis, and is really a breaking up of a mental state into the
component parts, understanding each part, so that they can be fitted
again with accuracy just like a jig-saw puzzle. Anything out of place is,
therefore, readily recognised, and re-education can be attempted.

The treatment of psycho-neuroses is no simple matter. Probably it
is just about the most difficult kind of treatment in the whole of
medicine. And why? Because we are dealing with that noumenon,
the mind, by which we think, we feel, and we act. Obscure and
numerous are the laws which govern our inheritance, and equally so are
those which lead to the transformation of matter into mind. It ill
becomes us to be dogmatic about anything in connection with
psychology, but there is one thing that I am certain of, and it is this:
that in the treatment of all mental cases, be they psychoses, neuroses or
psycho-neuroses, it is essential that the physician should be a man of
calm, thoughtful and sympathetic nature, and of sound common sense.

(') A paper read at the British Medical Association meeting (Scarborough
Branch), December 10th, 1919.—(’) Ref. Brit. Med. Journ., November, 1910.

Reform of the Penal System in Scotland .(*) By James E. Shaw,
D.L., Hon. Sheriff Substitute, County Clerk and Clerk to the Ayr
District Board of Control.

Apologia .—In presenting this paper I must crave indulgence. I feel
rather in the position of an inexperienced player who, from a spirit
of good nature, has been induced to “ make up a * four ’ at bridge.”
He will be lucky if he does not find at the end of the game that his
good nature is- taken less into account than his presumption.

It is not my design to deal exhaustively with this subject, which is far
too wide in its scope, too complex in its nature, and too important in its
character to be brought within the scope of a short paper, I propose to
submit for your consideration one or two alterations of our penal
system in Scotland which may be more or less far-reaching, but which,
with your forbearance, I hope to show by consecutive reasoning to
be at least worthy of serious investigation.

The subject .—The subject may be gruesome, but in this respect does
not so much concern the members of this Society as some of our
clients ; it is of interest to the theoretical lawyer, who may like to trace

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the principles underlying the constitution of a penal code from the days
of a nomadic existence through various stages to present-day commercial
and social life; it is not devoid of humour and is full of romance, but
withal practical from the present-day point of view; and it is from this
aspect that I propose to review certain circumstances of the penal
system in Scotland.

The object of a penal code or system in all well-regulated countries
ought to be primarily for the prevention of crime, and to establish pro¬
tection from crime to the community, and only incidentally as a means
to these ends to provide suitable and relative punishment for crime, on
conviction before a competent, fair and upright tribunal.

The punishment should not be vindictive, or designed and put
into effect in such a way as by hurt or injury to the criminal, in body,
mind or estate, to satisfy thereby the vengeance of the outraged person
or public. It should not amount to mere retaliation, which in itself
injures the avenger no less than the avenged. The punishment should
be educative or instructive, to the extent, at least, of showing that the
game is not worth the candle, and thereby teaching the criminal that it
is to his advantage to cease from crime, as well as to cause the potential
criminal to abstain. It should also be curative, whether by supplying
the want, removing the defect or changing the circumstances under
the influence of which the crime is conceived and committed.

When looking back upon the horrible and revolting punishments
inflicted upon criminals in Scotland within the comparatively civilised
period of the last two hundred years, one is forced to the conviction
that our worthy old jurists were bent upon vieing with the vengeance of
the Almighty as depicted in the Old Testament, and came out of the
contest with flying colours ; or, alternatively, that nothing but the most
severe measures would knock sense into the heads of the hardened
sinners of that day and generation and deter them from crime. The
keynote of the penal laws of that period, which in the main were
remarkably sound, was undoubtedly revenge—an eye for an eye—nay,
probably two eyes, e.g, in hanging a man for stealing a sheep. I am
one of those who consider that a great deal of harm is being done
in the present age by a silly, sloppy sentimentality; but I think there is
room for a great deal of improvement in the existing methods of
discovery of crime, the detection and trial of criminals and the treat¬
ment of convicts.

Of recent years there have been immense advances towards the
perfecting of our penal system on the lines indicated; and before
discussing proposals for the removal of existing blemishes, it is
well worth while to examine the very able writings of some of the
modern controversialists, among whom I should like to mention
more particularly the late Dr. Charles Mercier. It appears to be

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constitutional in such writers to set aside ruthlessly the theories of their
predecessors as “ unwarrantable in assumption, loose and inaccurate of
thought, vague of description, superficial of observation, and dogmatic
in assertion of absurdities as incontestable truths.” This leaves very
little to be said in the way of caustic criticism. But I, being of a more
enlightened school, prefer to accept and adopt each in their turn as
advancing the movement at least one step, and, building on their
foundation, to add my stone to the structure, well knowing that we are
yet far off the completion of the edifice.

Crime .—Crime is the commission or omission of any act whereby is
constituted an offence punishable by law. Every act or action of life
is instituted by two essential factors, the one internal, the other external.
This is true of all vegetable, insect and animal life. The internal is in¬
herent in its kind, while much more potent in some individuals of the
same species than in others. But all of the same species are to some
extent possessed of the same inherent characteristics. The external
factor may be persistent and cumulative, and will accordingly have
some influence in developing or diverting the inherent qualities, or it
may be only incidental and temporary, so as to provide an opportunity
for the exercise of an inherent ability. The external factor will also
vary in intensity and in the influence it will have upon any individual
of the species, but both the inherent and external qualities will together
and in combination to a varying degree influence the actions of any
individual under any given circumstances. This principle must apply
equally to every act, including a criminal act.

The internal factor may be called heredity or original sin, or any
other term, but there is undoubtedly an inherent ability to commit
crime in every human being, which requires the external factor intro¬
duced as a partner to enable the crime to be committed. The hereditary
or original or inherent instinct will be influenced by moral upbringing
and surroundings or habits acquired in early life. The external factor,
whether called environment, free will or some other phrase, is dependent
upon outside influences, such as motive, temptation or opportunity,
which will affect the actions of any individual in direct ratio to their
force upon the inherent quality of that individual. To cause a crime
to be committed, therefore, it is necessary that there should be a strong
inherent propensity, combined with slight outside influence, or slight
inherent combined with strong outside influence. An extremely
criminal mind will be influenced by very slight motive, yield to slight
temptation and probably make its own opportunity; whereas an upright
mind would require the incentive of a powerful motive, combined with
an opportunity which would in itself amount to an overwhelming temp¬
tation. The extent of motive plus temptation plus opportunity plus
inherent proclivity in varying degree being the necessary combination

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H 5

to constitute a criminal action should, therefore, be taken into account
in assessing the extent of turpitude or baseness of the crime.

The criminal .—It is a common mistake to speak of “the criminal
classes” when meaning the submerged class. We know that crime
permeates all classes, that every human being is bom in original sin,
and we have seen that in each and all of us there is an innate dis¬
position to crime which only requires a sufficiently powerful motive,
temptation and opportunity to complete the combination for effective
crime.

In early days, as appears from the Hebrew and Ancient Greek
writings, there was a very general distinction of the people, families or
tribes into the good and the bad—the sheep and the goats—and whole
families or tribes were ruthlessly decimated as unrighteous. This may
have been due to the paramount importance in those days of racial or
sexual proclivities, in crime, which having an adverse effect on the pro¬
gress of the race, must be stamped out like swine fever in pigs, and very
much by the same method. From that idea of propitiating the anger
of God by cutting off all wrongdoers, through various stages we come
to the view that it would be wiser by fear of punishment to deter the
potential criminal than by exterminating the race or family to which he
belonged, and the punishments determined upon were such as to leave
no room for doubt as to their being fearsome. From that it was an
easy stage to the opinion that the punishment, while primarily a deterrent,
should also have some effect in reforming the criminal so that he would
not fall again. Subsequently came the Italian School, with the rather
grotesque but attractive teaching that the poor goats could not of them¬
selves help being goats, and it was evident from their appearance they
were goats and not sheep. That, indeed, proclivity to certain crimes
could be detected in the physiognomy of the criminal, in the shape of
the skull, the thickness of the hair, the size, shape and position of the
ears, number of teeth, and so forth. Their habits also disclosed their
criminal propensity, and that they were in fact degenerates, and should
by education and treatment be reformed. It is not recorded that as a
result of the education or removal of motive or temptation or oppor¬
tunity, when any successful reformation was attained, the physiognomy
of the individual was effected so that the shape of the skull altered, the
hair grew or ceased to grow or the ears changed in shape, but that did
not disprove the theory. As a result probably of the extravagance of
the last-mentioned theory, the next line of argument veered round to the
extreme opposite—that crime was to no extent due to inherent quality, but
solely to environment, such as faulty or deficient education, dissolute
parentage and squalid surroundings; and that with good drainage,
education authorities, proper housing schemes and prohibition of the
liquor traffic, crime would disappear. It seems to have been overlooked

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that crime does occur in the highest circles and among the most erudite,
though possibly, owing to motive and temptation being less insistent,
the inherent quality is less frequently invoked. Then comes the theory
that all criminals are insane—insane because they are criminals, and
criminal because insane, which cannot be accepted as useful or prac¬
tical in the result to which it leads. This is followed by a theory which
seems to be based upon Mendelism—that a certain definite fixed pro¬
portion of the population are criminal, which was arrived at after a
most painstaking examination of statistics, and we all know the value of
statistics. And now we arrive at the latest doctrine propounded by
the learned and logical Dr. Merrier, that the “ criminal act is due to
temptation or opportunity as the environmental factor acting upon
predisposition.” It seems a mistake to exclude motive as one of the
external factors, because, while some crime may appear to be without
motive, it is by no means usually so.

The general criminal is a rara avis. For the most part criminals
specialise in some particular class of crime in which they become more
or less adepts, and are known for their style and capability of execution.
In this they are no doubt guided by training and upbringing, e.g.,
mechanics to burglary, solicitors, financiers and such-like to fraud,
artists to counterfeiting, fishermen to smuggling and wrecking; and
having adopted a speciality, they seldom if ever depart from it. It must
have occurred to many of them as well as to onlookers that the same
amount of thought and energy applied to an honest calling would com¬
mand more fruitful results. An inordinate selfishness of character,
devoid of any higher ideal than immediate personal gratification, and
the want of sufficient self-control, are probably the most prevalent causes
of a career of crime. A distinguished student of humanity tells us that
“there is no character which has not some redeeming points; pure
unmixed wickedness is the creation of romance, but never yet appeared
in real life,” and he very closely examined an extensive period of real
life. He gives as an example the unlikely case of Burke, who was tried
in 1828 for three cold-blooded murders perpetrated under repulsive
circumstances, and who no sooner heard the verdict of the jury which
found him guilty and acquitted his associate, a young woman who was
tried along with him, than he threw his arms around her neck and
kissed her, saying, “ Thank God, Mary, you are saved.” The writer
whom I quote, and who conducted the prosecution on the part of the
Crown, records his wondering at the time “ how many of his judges,
jury or accusers in similar circumstances would have done the same.”

Discovery of crime and detection of the criminal .—In the prevention
of crime a most important consideration is that it should be rendered
an unprofitable pursuit, and this can best be accomplished by making
the discovery of crime swift and the detection and conviction of

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the criminal sure. No one will commit a crime for gain in face of the
practical certainty of being immediately discovered and losing the
advantage which the crime was intended to confer. Misdirected energy
will not go so far as this, with the attendant disadvantages. When
Solon was asked which was the best policed city he replied, “ The city
where all the citizens, whether they have suffered injury or not, equally
pursue and punish injustice.” This is perhaps rather far-fetched, but
certainly all citizens in this country might contribute towards the result
to a greater extent than they do. Very few will submit themselves to
the inconvenience of informing except under the influence of excite¬
ment, and in view of the appalling conditions to which they are sub¬
jected in the average police-court they are scarcely to be blamed. They
might, however, bear the irritation of an effective registration system, to
which they would very soon become accustomed, as a necessary evil for
their protection. It is disconcerting to find that in only about 15 per
cent, of indictable offences reported are convictions obtained, and, if this
is correct, it leads one to suppose that the proportion of convictions
to crimes committed is very small indeed. Such a state of affairs almost
amounts to an incentive to crime. It has been shown that all are
potential criminals, and that previous conduct gives an indication of
the probability of lapsing into crime, also that criminals specialise in
particular classes of crime which they carry out with very pronounced
individual characteristics. As a matter of fact, experienced detectives
recognise the craftsman by his method of procedure, pretty much in the
same way as a writer is known by his style of writing or a tradesman by
the character of his work. Accordingly, with the help of a complete
and satisfactory register kept reasonably up to date, with a proper record
of crimes and a skilful classification of known criminals in frequent
circulation, detectives should be able to drop on the individual wanted
with incredible promptitude and certainty. I do not know how far such
a system may be already in operation, but it is certainly not in full and
complete operation. I know that it has been successfuly tried to a
limited extent in England, and the identifying marks are class-word,
entry, means, object, time, style, tale, pal, transport, trade mark.

The assise .—The trial is perhaps the most important link in the whole
chain of the penal system, and at the present day it may be said to be
the weakest. As an amateur judge of some years’ standing, I hope I
may be free of envy or disloyalty when I say that such judges as
honorary sheriffs, justices of the peace, baillies, etc., should be entirely
swept away ; but I would bring them back in another form. There is
no sound reason why minor crime should be dealt with more loosely
than major crime, but rather as the minor offence is generally the first
step in that loss of self-control and giving way to inherent criminality
which leads to the establishment of an apprenticeship, culminating in
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some speciality of crime, it is all the more important that minor crime
should be tried with the greatest possible care and by a thoroughly
competent judge. For this reason I think there should be constituted
a sufficient number of stipendiary magistrates, but not necessarily drawn
from the Faculty of Advocates. Also, with a view to avoiding that
fruitful source of the creation of criminals, viz., the wrongful conviction,
should there not be a public defender as well as a public prosecutor ?—
a lawyer of equal standing and experience as the public prosecutor, who
by constant application to one special subject would become expert
therein. The accused would then have the best available line of defence
adopted for him, and incidentally the time of the Court and the public
purse would be saved. It is not suggested that an accused should not
be permitted to engage his own pleader to supersede or assist and
superintend the public defender any less than an accuser has power to
prosecute on his own account, but that a public defender selected for
his ability should be available, and in practice it would become as rare
for the accused to defend by private agent as it is for the accuser so to
prosecute. A common experience in trials which has struck me as
peculiarly inept is the way in which the judge who is a lawyer is called
upon to decide technical questions altogether outwith the scope of the
law. It may be said that he has the advantage of expert advice given
in evidence, but he has often to decide between the conflicting evidence
of experts on a subject of which he can have very little knowledge, and
if the evidence does not conflict there seems to be no reason why he
should hear it at all. Take, for instance, the very ordinary plea of
insanity. This is a purely medical question, and should be decided by
doctors. It has been laid down that a man of forty years is either a
doctor or a fool. All our learned judges are over forty, and none of
them is a fool therefore each is a doctor. But this is not quite good
enough to depend upon in a crisis. The procedure, as is well known,
varies according to the degree of insanity, the gravity of the crime, and
whether the defender or the inspector of poor is prepared to incur
expense, also whether the panel is not called upon to plead, or the case
goes to a jury to decide as to the panel’s sanity at the time of the trial or
at the time of committing the crime, all at the discretion of the prose¬
cutor. There seems to be no good reason for this variety in procedure.
The question before the House is that the prisoner is insane. This
should be determined by medical experts, and the prosecutor should
have no discretion in the matter. The present procedure very often
puts the cart before the horse, causes a great deal of useless expense,
and sometimes inflicts much avoidable cruelty. A client of mine in
good circumstances, a retired naval officer of eccentric habits, after a
protracted and painful illness brought on by financial worry got up
from bed and shot his wife. The gun was then taken from him, but

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he intimated that it had been his intention to shoot his son and the dog
and cat before shooting himself, and possibly the hens if the ammuni¬
tion lasted, but he was not sure about them. He was dragged from his
sick bed and placed in a police cell. The following day he emitted no
declaration, was examined and certified insane by the police doctor and
a mental expert on removal to the prison at Ayr. He was there
detained for four months until removed in sight of the public from
Ayr to Duke Street Prison for trial in Glasgow, and suffered what to
him was the greatest indignity, removal in Black Maria, “ herded with
common criminals,” from Duke Street to the Justiciary Court
for trial. The plea in bar was accepted on the evidence of the two
doctors mentioned, being the only doctors who had examined him, and
the usual order was issued. I immediately made application to the
Secretary for Scotland, with the necessary guarantees, that he might be
removed to an ordinary asylum, and asked that he be retained at Duke
Street while the petition was being dealt with to avoid the removal to
Perth. The answer received was that the Secretary for Scotland did
not consider a prison a suitable place to retain a lunatic. I agree, but
remark that he had already been four months in prison after being
certified. He suffered a short sojourn at Perth before removal to an
ordinary asylum, where he died. Is this not a shameful instance of
unnecessary expense and trouble ? Another client of mine, who was a
known epileptic from his youth up, under stress of motive, opportunity
and temptation became a poisoner. The crime was cunningly devised,
and the extremely able council retained for his defence determined not
to plead insanity, as he hoped to get him off. The case went to trial,
but fortunately no doubt for friends and relatives, the jury, on the
instructions of the judge, found him insane, and he also died in the
asylum after a visit to Perth. Surely this was a medical question, and
not one for council, judge or jury. Consider the danger involved had
the jury not so decided. Lastly, in a recent case a man was tried for
murder, with all the pomp and circumstance, not to say expense, of a
Circuit Court. No plea in bar was tendered, and the medical evidence
was as to the effect of alcohol on the actions of a man who had suffered
from malaria. He was convicted and sentenced to death, with a
recommendation to mercy, and a petition for reprieve was lodged.
Then, and not till then, was the man medically examined by mental
experts. A retired Commissioner in Lunacy, sent up from England,
along with a junior Scottish Commissioner, examined the convict, and
on their report the man was reprieved. And this after all the expense
and trouble of a Circuit Court.

My suggestion is that no technical question such as insanity should
be decided by a judge or jury, but should be referred to expert arbitra¬
tion, with a technical expert as referee in the event of disagreement.

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Thereafter, if the report of the referee, whenever such a reference is
necessary, does not bar the trial, the questions of fact and law should be
tried by a judge to decide whether the indictment is proved against the
panel. Further, that no one man should have power to inflict punish¬
ment upon another, and if the judge determines that the panel is guilty,
a jury or committee of responsible citizens of good moyen and estate
should, after hearing parties, and on the facts found proved by the
judge, determine the punishment according to the extent of turpitude,
taking into consideration motive, temptation and opportunity, as well as
any other circumstances that weigh with them.

Treatment of convicts .—We have seen that crime is largely misdirected
energy due to an external influence acting upon an inherent capability,
and that the treatment or punishment for this crime should be curative,
as well as being designed for the protection of the community from
crime and the prevention of crime.

Let us therefore abolish the existing punishment of penal servitude
and imprisonment as barbarous, and only tending to harden the
criminal instinct among those who survive, as useless for the purpose
for which it is intended, wasteful in expenditure and hopelessly
inappropriate. Let us rather guide and make use of the energy that is
misdirected in crime by first restoring the damage it has done, and
thereafter allowing the criminal, under proper supervision and control,
to make good for himself as well as for others.

The jury or committee for the punishment of criminals, in view of
the considerations above mentioned, would, in the first place, assess the
damage caused by the crime for which the criminal should become
responsible, allowing him a living income from his earnings ; then,
according to circumstances, they would award a varying period of police
supervision and degree of frequency of report. With a proper registry
system there should be little difficulty about obtaining employment and
encouragement to lead a normal life in suitable surroundings to the
benefit of the State, and so save the convict from “ a most dangerous
downfall, whereby the devil doth thrust them either into desperation
or into wretchlessness of most unclean living, no less perilous than
desperation.”

I can hear doubters suggesting the difficulty of engaging a murderer
as process clerk, a fraudulent cashier or a burglar as conveyancing
clerk. But how much do you know of the inner life of your clerical
staff, their inherent disposition, their motives, ambitions, temptations
and opportunities ? Remember that, as all criminals would be medically
examined, those having no power of control would be eliminated.
There would, of course, be lapses, and these would be punished by
closer supervision and more frequent report. If the lapses became so
frequent as to point to total incorrigibility, his employment in useful

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work would become impossible, and then the criminal must be cut off,
washed out entirely, and no time wasted upon ineffective imprisonment.
He is better dead, for himself and for others.

I feel that such a system requires much more development and
elaboration before it can be made quite clear and intelligible, but it is
the fashion of the day to evolve schemes for renewing the earth without
clearly and explicitly stating how they are to be carried into effect. If
I adopt the fashion, it is not because I have failed to work out or study
the details, but because it would be monstrous to further encroach
upon your indulgence.

Conclusions.

(1) That a general register of the people be compiled and kept up to
date, together with a special register and classification of criminals to be
circulated among police forces.

(2) That a public defender be attached to every criminal court as well
as a public prosecutor.

(3) That stipendiary magistrates be appointed in substitution of all
honorary judges.

(4) That medical referees be attached to all criminal courts to examine
and report upon all criminals when necessary, anterior and as a pre¬
liminary to the trial on fact and law. This might be extended to all
technical questions that might arise, e.g., engineering, shipping,'mining,
finance and others.

(5) That the decision of the judge be confined to the elucidation of
evidence and findings in fact and law to determine the guilt of the panel
as charged.

(6) That a jury or committee be appointed to assess the damage and
determine as to the treatment of the convict.

(7) That the existing punishments of penal servitude and imprison¬
ment be abolished, and a carefully-thought-out scheme be instituted to
enable the convict in the first instance by the fruit of his work to restore
the damage done by his crime, after maintaining himself, with a view to
his eventual restitution to all civil rights and liberty.

(8) That those criminals who prove incorrigible be destroyed.

( ] ) Paper read to the 35th Annual Meeting of the Incorporated Society of Law
Agents in Scotland, October 23rd, 1919.

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Occasional Notes.

Progress of Psychiatry in England.

After reading the remarks of the Lancet for March 6th, 1920, under
the heading, “ The Reproach of Psychiatry in England,” it is with some
diffidence that one speaks of “ progress of psychiatry in England.”
Yet progress there has been, sporadic and intermittent it is true, but
nevertheless progress. “ Backwardness ” as regards psychiatry is rather
relative than absolute, and is not applicable to the whole subject, but
limited to scientific teaching and organised research. There are
few or no indications in those countries which are reputed to be
“ forward ” in this branch of medicine of more success in treatment,
especially in the permanent cure of either early or established cases,
while no country surpasses this as regards the care and accommoda¬
tion of those mentally afflicted. The general view of English psychiatry
—and one not without some foundation—is that much of the progress
of psychiatry so well boomed as occurring abroad and not at home
ends very largely in paper, verbosity, and high-sounding terminology,
and the attitude taken up is in large measure that of the critic and sceptic.

It must be admitted, however, that, after all has been said, the
remarks of the Lancet , as far as they go, do not incorrectly describe the
situation, and we are bound to admit that a reproach exists. Happily
there are at present signs and symptoms of a great awakening in this
country to the needs of psychiatry, and let us hope that, though delayed,
the progress foreshadowed will be solid and durable and attain the objects
in view, i.e ., the definite entry of the treatment of mental diseases
and the cure of insanity into the current practice of medicine. Too
long have the insane been considered a class of people needing mainly
separate care and special segregation, who only resume their full
citizenship on recovery. No doubt such has been necessary in the past,
and perhaps the only way, and the benefits that have come to them
thereby are undeniable. Daylight now enters freely the institutions for
the insane, humane treatment is uppermost and they are administratively
admirable. Progress in this direction would appear now to have
reached its limit in this country, and the high degree of efficiency
attained is not a reproach, but the opposite, and we can afford to some
extent to rest on our laurels in this respect.

The time has come to turn our efforts rather to the removal as far as
practicable of the insane from their traditional sectional treatment, con¬
sidering them merely as patients suffering temporarily or permanently
from one of the ordinary current diseases and disorders. Along these
lines must future progress be made. To further this the mental hospitals
need to be linked up with the hospital system generally, and psychiatry
more closely interwoven with ordinary medical and hospital practice.

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The first step in this direction was the creation of the trained mental
hospital nurse, and the second the establishment of psychiatrical train¬
ing for doctors and diplomas in psychological medicine. The war has
retarded matters somewhat, but this has not been without its advantages,
since methods of care and treatment have been rendered possible which
Undoubtedly will make their influence felt in the future.

At the last quarterly meeting of our Association, reported in this
Journal, reference was made to the pioneer work of the special com¬
mittee which came into being as the outcome of a communication by
Colonel D. Thomson on post-graduate teaching and training in
psychiatry in 1908. The result was the establishment of diplomas in
psychiatry and psychological medicine by the Universities. It was
decided that the time has come now for further progress in this direction,
and a committee was instituted, having for its reference—“ To consider
the best method and facilities for training in psychiatry and for
obtaining the diplomas which exist.”

In a recent paper read before the Association, Dr. C. Hubert Bond
advocated the establishment of mental cliniques at the general hospitals,
and closer relationships between the mental hospitals and the general
hospitals as regards teaching, research and treatment. This paper by
Dr. Bond was a well-timed stimulus to action, and the Association
would be betraying its trust if it did not take energetic steps to further
the proposals made. It has definitely done so by the appointment of
this special committee, for both these matters are indissolubly bound
together.

Too long has psychiatry been in a great measure isolated from
general medicine and left to struggle alone. The cure of mental
diseases is in actuality the most difficult problem which for ages past
has faced the medical profession, and a problem which calls for the
application of the acutest intellects in our ranks for its solution. Not
that psychiatry has not now, as in the past, illustrious men entirely
devoted to it, but its very complexity demands the greatest efforts
possible of the profession. Until a person who has become afflicted in
mind has a reasonable prospect of a speedy and permanent cure the
public will be dissatisfied and a reproach will remain.

We work under many difficulties and disadvantages which must be
capable of some solution. The great drawback has been the difficulty
in obtaining a steady flow of the best men from the hospitals to the
asylums and the practice of psychiatry in general. The heads of the
profession have not always been with us, and have been often even
against us. Administrative and clerical work, very ordinary medical work
with little or no surgery, and general professional stagnation have been
the gravamen urged, and this is the real sting of the reproach. How far
it is true or otherwise the members of the Association know, but it

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should be remembered that medical administration, under the en¬
lightened control of the many lay committees, has in any case raised
the mental institutions to their present high level of efficiency.

Medical administration has been necessary in the past, and always
will be. The trouble is that administrative duties and responsibilities
increase as juniors become seniors and seniors become medical super¬
intendents, with the result that as medical experience increases in value
to the patients, the opportunities for concentration on purely medical
work decreases, until, in the case of the medical superintendents, it is
often almost entirely crowded out by administrative duties. Progress
in the treatment of mental diseases necessarily suffers, and will do so so
long as matters remain as at present.

Some reconstruction and rearrangement of the medical and admini¬
strative work in the mental hospitals would appear to be imperative if
the full benefits of the psychiatry and research work of the future are
to accrue to the patients. It is neither possible, nor is it the place, in a
short “occasional” to deal adequately with the matter; but there appear
to be three fundamental principles which, we venture to suggest, should
guide the Association when the time comes to formulate its views:

(1) The responsibility for the management of the mental institutions
is a matter for local authorities and committees and their medical and
other advisers.

(2) The care, custody and cure of mental patients is a national and
not a local responsibility, and should be in the hands of a medical service
subject to Parliamentary and not local control.

(3) The duties and responsibilities of local authorities and the
medical profession should be allocated in accordance with (1) and
(2) in order to secure the carrying out of (2).

In conclusion we desire to offer our congratulations to the London
County Council and Sir Frederick Mott on the completion of the
scheme for the giving of lectures and practical instruction in psychiatry,
rendered possible by the enlightened views and generosity of the late
Dr. Henry Maudsley, who, it is regretted, did not live to see either the
Maudsley Hospital completed or be present at the opening of the first
session of London’s great school of psychiatry. Sir Frederick Mott’s
words, written in the Archives of Neurology for 1907 and quoted by the
Lancet (see p. 558), are bearing good fruit, and generations of students
to come will have good reason to be grateful to him for the prominent
part he has taken in the genesis of the Maudsley Hospital.

Studies in Mental Inefficiency.

We have received the first number of this new publication, which is
issued by the Central Association for the Care of the Mentally Defective.

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This Association has already done work of considerable social value,
and this publication should not only serve to give greater publicity to
its aims, but it should become an educational medium of great usefulness
to the increasing number of the public who are concerned directly or
indirectly with the problem of mental deficiency. The journal should
supply an obvious need. Hardly sufficient interest is shown by the
public in the sociological problems included under the wide term
“mental inefficiency”—the criminal, the mentally deficient and the
insane—and this publication may do much to stimulate interest in
these directions. It is starting in a modest way and we wish it every
success, and we may perhaps express the hope that it may so receive
the support of the medical profession by contributions of interest and
value, and that of the public by subscribing to it, that it may eventually
attain the importance and dimensions as have journals with similar
aims in other countries. The opening number has the advantage of a
sympathetic foreword by Dr. Shuttleworth, who has done so much for
the mental defective, and it includes interesting papers by Dr. Tredgold
and Miss Fildes.

Part II—Reviews.

The Autonomic Functions and the Personality. By Dr. Edward J.
Kempf. Nervous and Mental Disease Monograph Series, No. 28.
New York and Washington, 1918. Royal 8vo. Pp. 156. Three
Illustrations. Price 8a.

Most of the readers of this journal will recollect how scanty was the
attention paid in their student days to the study of the sympathetic
nervous system. It was deemed to be of little account except in so far
as it influenced the action of the heart and the processes of digestion.
Compare with this neglect the amount of instruction given in the
anatomy and physiology of the cerebro-spinal system. And this state
of the case in the medical schools was but a reflection of the literature
of the day.

Times have changed, and there now appear in bewildering succession
books and articles on what some call the vegetative, others (including
the present author) the autonomic system. The book under considera¬
tion deals, then, with the autonomic or sympathetic system, and it is
written to show the enormous effect this system has upon the behaviour
and personality of man. It is divided into four parts. Part I is mainly
anatomical; Part II, physiological; Part III deals with the psychology
of the matter, and Part IV is a brief recapitulation.

Whatever may be the exact views held as to the relationship between
mind and matter most of us cling to the general idea that the seat of
the mind is the brain. The theories of our predecessors that the

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heart, the liver, and other viscera had to do with the emotions are
regarded with an indulgent smile as belonging to antiquated thought.
It is a considerable shock therefore to be told in a modem book that
ours is an “ old notion ”; that the sole reason for the idea of the mind
being situated in the brain is the fact that the eyes and ears are set in
the head. So says the author of this book. But the mind, where is
it ? He replies: “ In the autonomous system.” The autonomous
system is the lord, the cerebro spinal, the humble servant who merely
obeys his master’s bidding.

Professor James had partly prepared us for this revolution by his
theory of the origin of emotions, but Dr. Kempf goes further, and in
his opinion not only emotions but desires and thought are due to
changes in the sympathetic nervous system.

There is naturally a considerable amount of resistance to be over¬
come before such teaching can be seriously entertained, but Dr. Kempf
argues his point of view with considerable courage and erudition. His
book is worth reading for the manner in which he has collected and
collated the experimental work of Sherrington, Cannon, Crile and a
large number of other writers. As regards his psychological outlook he
is an ardent follower of the teaching of Freud, and from another point
of view this book may be regarded as an attempt to show the physio¬
logical mechanisms underlying the psychological phenomena known as
repression, wish-fulfilment and the like.

It will be realised that adequate discussion of the problems men¬
tioned are impossible on the present occasion. With regard to minor
criticism it must be stated that in parts of the book the arguments
would have appeared more convincing had they been better arranged.
There is evidence of haste in writing, and some revision and reconstruc¬
tion will be beneficial in a second edition. To give one example:
“ Another confusing practice of some psychologists, that has been the
cause of considerable confusion, is the tendency to consider that an
emotion either exists or does not exist, and that it exists in the
personality by itself as a free agent that may attach or detach itself to
objects, people, ideas, etc.”

This is one of several passages marked as difficult to comprehend.
These, however, are small faults which can easily be corrected, and
on the whole Dr. Kempf is to be congratulated on his efforts to throw an
entirely new light on the workings of the mind and the personality of
man. R. H. Steen.

Sexualpathologit: Ein Lehrbuch fitr Ante und Siudierende . By Dr.

Magnus Hirschfeld. Bonn: Marcus & Weber, 1917-18.

Parts I and II, pp. 211 and 279. 8vo. Price m. 40.

It is thirty years and more since Krafft-Ebing published the first
edition of his clinical and forensic study, Psychopathia Sexualis , and
although that work still continues to appear in ever-enlarged and
modified editions, it no longer corresponds to the present outlook of
scientific investigation. Dr. Hirschfeld, of Berlin, who possesses an
unequalled knowledge of the pathological side of sex, acquired during

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twenty years of special practice in this field, has therefore here made
an attempt to supplant Krafft-Ebing’s book as a manual for practitioners.
Two parts have already appeared.

The author has discarded Kraflft-Ebing’s title. Sexual pathology is
no longer concerned only with psychic facts; we have learnt how
intimately in this field the psychic depends on the physical, and Steinach
has shown how by simple transplantation of sexual tissue it is possible
to masculinise, to feminise, or to hermaphroditise an organism. It is,
above all, the new doctrine and the new knowledge of the internal
secretions which has revolutionised sexual pathology. Hirschfeld
remarks in the preface that the endocrinic doctrine is the Leitmotiv of
his whole book, to be heard in every chapter. But he adds that the
book is purely clinical, proceeding from a consulting room and not from
a study ; every case brought forward is from his own practice, and some
of them have been under observation for ten, fifteen, or even more
years. This personal character of the work has its disadvantages when
it is a question of a text-book for general use, for Dr. Hirschfeld is
sometimes negligent and even inaccurate in his references to the work
of other investigators, even when they bear most clearly on his own
work, but the positive value of the treatise remains little impaired.

The absence of the sexual glands and the results of their removal are
first dealt with, including eunuchoidism (or testicular hypoplasia), and
the various aspects of the subject of castration in males and females,
including the accidental castration (for the author finds no evidence of
intentional mutilation) occurring during the war. The next chapter
deals with infantilism, in what the author regards as its four funda¬
mental forms—genital, somatic, psychic, and psycho-sexual; inci¬
dentally cryptorchidism and dwarfism are discussed, as well as the
various aspects of padophilia erotica , in connection with which Hirsch¬
feld states (contrary to the opinion formerly expressed by others) that
he has never known an outrage on a child to be committed by a subject
who was not found on careful examination to be seriously defective
mentally. A varied and interesting chapter on precocity, considered
in the same four forms, is followed by a chapter on sexual crises.
This is a comprehensive discussion of the various psychic and nervous
disturbances associated with puberty, menstruation, pregnancy, and the
climacteric. The first volume concludes with instructive chapters on
masturbation, for which Hirschfeld (following Kurkiewicz of Cracow)
prefers the word “ ipsation,” while (following Rohleder) he uses the
term “ ante-monosexualism ” for that variety in which the subject feels
a psychic attraction to his own body ; there seems, however, no good
reason for abandoning the term “narcissism,” usually given to this
variety. Hirschfeld presents a curve, based on over 500 cases, showing
that twelve to fourteen is the most usual age (44 per cent.) for beginning
masturbation, and he considers that its prevalence in the two sexes is
about equal, though it tends to begin much later in women than in the
other sex. There is no reliable indication of masturbation and no
specific disorder connected with the practice. On these points be con¬
firms other recent investigations.

The second volume deals with those various intermediate sexual
stages, somatic and psychic, concerning which Hirschfeld is already a

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recognised authority and the author of several extensive monographs.
In these condensed chapters, richly stored with facts, he summarises
his earlier work and brings it up to date. The subject as a whole he
entitles “ hermaphroditism,” that is to say, the mixture of the opposed
sexual characters, or, as Orth put it, “the confusion of sexual
characters.” Hirschfeld recognises four groups of hermaphroditism
and devotes one or two chapters to each : (i) Genital hermaphroditism,
until recent times the only form recognised; (2) androgynia, or the
general physical mixture of sexual characters ; (3) psychic hermaphro¬
ditism, or the mixture of psychic sexual characters, by Hirschfeld
named “ transvestism,” which seems too narrow a name, so that the
present reviewer has proposed the term “ eonism,” after the Chevalier
d’Eon, the most famous representative of the type; and (4) psycho-
sexual hermaphroditism, that is to say, homosexuality or sexual inver¬
sion, together with what Hirschfeld terms “ metatropism,” by which he
means an inversion of the ordinary tropisms of the sexes, the man
passive instead of active, and the woman active instead of passive.
This last division is new, and is based on the conception of Krafft-
Ebing that in men there is a normal tendency which has its extreme
pathological form in sadism, and in women a normal tendency with an
extreme pathological form in masochism. It is not probable that this
conception, in the formal and precise shape into which Hirschfeld
puts it, will be universally accepted. There are many female sadists
and more male than female masochists. It seems quite possible to
argue that the supposed general activity of the male and general
passivity of the female is largely a conventional notion based on
prevailing social modes, and not so deeply rooted in Nature as to be
true of all forms of male and female activity. It may be roughly true
of our current practical life and yet not be susceptible of conversion
into a fundamental biological doctrine.

A third volume, not yet published, will complete the work. When
thus completed, there can be little doubt that this text-book will prove
of much practical value, alike from the psychiatric and the forensic
standpoints. It should be added that the numerous illustrations are
of high quality and much interest. Havelock Ellis.

Dream and Primitive Culture. By W. H. R. Rivers, M.A., M.D.,
F.R.S. Reprinted from The Bulletin of the John Ry land’s Library.
Longmans, Green & Co. Demy 8vo, pp. 28. Price ir.

It must be admitted by even the bitterest opponent of Freud’s
theories and writings that they have stimulated research in other
matters which at first sight would appear to have little in common
with them. Thus, for example, there are books upon “dreams
and myths” and “wish-fulfilment and fairy tales.” The subject of
the present review is a lecture which was delivered at the John
Ryland’s Library on April 10th, 1918, and it deals with the resem¬
blances which are to be found between dreams and the customs of
savage peoples. Much of the material has been obtained from study
of the Melanesian or Papuan cultures, and the greater part from the

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social life of the inhabitants of one tiny island only two miles in
diameter—“ Mota of the Banks group.” The lecturer deals with his
subject in the same manner as Freud describes the dream-work. He
takes up one by one the questions of distortion (here called “trans¬
formation ”), dramatisation, symbolisation, condensation, displacement,
and secondary elaboration. He then goes on to consider the censor,
wish-fulfilment, rdle of sex, and finally the unconscious. Explanations
are made of the meanings of these terms, and illustrations of similar
processes are given as they occur in the primitive races.

For example: “A native of Mota in the Banks Islands, who is
marking out a plot of ground which is to be the property of an unborn
child, carries a dried cocoanut under his left arm or on his left shoulder
as a symbol of his purpose.” On inquiry it will be found that the man
attaches great importance to this simple object, and regards its use as
essential to the proper performance of the work upon which he is
engaged. How foolish and absurd this custom seems to be, and just
as ridiculous as the manifest content of many a dream! Yet when the
matter is investigated scientifically it will be found that the cocoanut
represents the human head, and interwoven with this idea are various
beliefs regarding the soul, the danger and sanctity of the head, etc.
To use the terminology of dream-study, the manifest content of the
custom appears foolish while the latent content is full of meaning.

Dr. Rivers acknowledges his adherence to the dream-psychology ot
Freud. It is not to be understood that he follows the latter’s teaching
implicitly in all points, but in the main, and especially with regard to
the psychological mechanisms involved in the production of the dream,
he asserts his belief in the correctness of Freud’s work. He is further
of opinion that his studies in anthropology offer one more proof of this.
It is unfortunate that so much learning and research had to be com¬
pressed within the narrow limits of a lecture. So highly condensed
has the material been that it has been impossible to epitomise it in
any way with justice to the author. It is earnestly to be hoped that
Dr. Rivers on some future occasion will expand these few pages into a
book and so reach a wider circle. R. H. Steen.

Studies in Word-association: Experiments in the Diagnosis of Psycho-
pathological Conditions carried out at the Psychiatric Clinic of the
University of Zurich. Under the direction of C. G. Jung, M.D.,
LL.D. Authorised Translation by Dr. M. D. Eder. London:
William Heinemann. Pp. 575, demy 8vo. Price 25 s.

In the earlier work in psycho-analysis use was made of two methods—
“free association,” in which the subject tells all the thoughts which
come into his mind, avoiding criticism as far as possible; and the
interpretation of dreams. It was soon found, however, that in some
patients the associations came to an abrupt stop and that no dreams
were forthcoming. Dr. Jung suggested the use of the word-associa¬
tion test, and this has been generally adopted as a third means of
obtaining an insight into the mental state. He and his fellow-workers
published numerous papers on this subject which are scattered through

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periodicals in the German language, and we are indebted to Dr. Eder
for translating these and collecting them under the covers of one
volume.

It is, of course, most essential before discussing the use of any
method in abnormal people to have a clear understanding of how it
behaves in the case of the healthy. It is therefore not surprising to
find that more than one-fourth of the book deals with the associations
of normal subjects. A comprehensive table is given of Jung’s classifi¬
cation of reactions and the percentages of these met with in different
types of humanity with and without distraction.

Among the conclusions reached after experiments on normal subjects
are the following: ( a ) That reduction of attention through any kind of
inner or outer impulses makes the reaction type a more superficial one—
that is to say, the inner or higher associations recede in favour of outer
associations and clang reactions. ( b ) Indirect associations are increased
when there is distraction of the attention. ( c ) The educated have on
the average a more superficial type than the uneducated, (d) As to
the degree of the dissociation of the attention caused by distraction,
there are no essential differences between the educated and the
uneducated.

Jung then proceeds to describe two types of mankind revealed by
the experiment—the objective and the egocentric. This work probably
laid the foundation for his ideas on the extroverted and introverted
varieties which are discussed in a later paper (“Analytical Psychology,”
C. G. Jung, translated by Constance Long, Chapter XI).

After the very elaborate discussions of the normal psychology there
are chapters on the use of the test in imbeciles, epileptics, cases of
hysteria and in families.

Scattered through the book are references to complex-indicators and
a short chapter summarising these would be welcome. For the benefit
of our readers they may be given as follows : (i) Increase in the time
taken to give a reaction. This is one of the most important signs and
is dealt with in detail in Chapter V. Sometimes the patient is unable to
give any response to the stimulus word within a reasonable time, say
half a minute. (2) The nature of the reaction. This may be super¬
ficial or even an apparently senseless one. The subject may not hear
the stimulus word aright, which will have to be repeated, or he may
himself repeat the stimulus word. At times the word given as the
reaction is used several times. This word may be given in a foreign
tongue and in an energetic manner. Frequently after a long reaction
time the immediately subsequent reactions are upset through persevera¬
tion. The whole behaviour of the patient must be watched and noted.
A foolish laugh or emotional disturbance may occur during the test
without any apparent reason. (3) On the completion of the test the
subject is asked to repeat his reactions and failure to do so is of
significance. This is dealt with in Chapter X.

Taking the book as a whole there is a sense of inequality in the
material provided, and it is suggested that several chapters might well
be dispensed with in a later edition without diminishing its value.
These remarks do not refer to those written by Dr. Jung, which are
always interesting and suggestive. It is certainly most instructive to

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have complete examples such as are given in Chapters VII and IX of
the use of the method by the designer of the same.

Even apart from psycho-analysis there can be no doubt that the
word-association test will occupy a more prominent place in the future
than it has done in the past. There are many possibilities of its value
in diagnosis and prognosis. This book will be indispensable to anyone
who wishes to make use of the method and should be in the library
of every mental hospital.

Considering the fact that the subject-matter deals with words Dr.
Eder had no easy task. He has used his discretion to introduce
more suitable English words when the literal translations of the original
words would have conveyed no meaning. He is to be congratulated on
the excellence of his work. A comprehensive bibliography is appended
and adds considerably to the value of the book. R. H. Steen.

The Dawn of Mind. By Margaret Drummond, M.A. London:

Edward Arnold, 1918. 16 mo, pp. 179.

If the perusal of this book will make the average mother take an
intelligent interest in the growth of her child’s mind it will serve a
useful purpose. Anybody who tries to And out why and how babies do
things is apt to be regarded as an unfeeling wretch since his endeavours
tend to correct the delusions which women cherish about their off¬
spring. As a consequence an important psychological field is left
almost untilled. The author of The Dawn of Mind, perhaps because
the children she describes are not her own, achieves a considerable
measure of detachment. Misgivings may arise as to her method if the
reader, on taking up the volume, should happen to open it at p. 25 and
read that “ Baby, like the wise little person he is," does something or
other, and the frontispiece may strike him as futile, but these minor
blemishes convey quite a wrong impression of the book, which is really
full of sound sense and entitled to respectful consideration.

In a preliminary chapter some particulars of the nervous system and
its functions are given. The information is, no doubt, full enough and
accurate enough for its purpose, though it implies a simplicity about
the nervous organisation of the human body which is rather misleading.
The “ reflex wink ” does not seem to be a particularly happy example
of activity confined to “ the lowest level of neurones." It supports,
rather, the view that reflexes are produced from volitional activities by
a process of degeneration. Speaking of the earliest stages of reasoning,
the author says—“ at first we notice likenesses rather than differences."
The accuracy of this statement is open to question. The “ likenesses ”
which appeal to the infant mind are probably “ likeablenesses " rather
than the resemblances which exist for the adult. In testing the intelli¬
gence of children it is found that the age at which they recognise the
differences between related articles, e.g., fly and butterfly, is several
years below that at which features of similarity are described. Speech
is treated of as wholly acquired, though it is noted that a child who
presents defects in his later speech “may have made the required
sounds quite correctly in his baby prattle.” This fact, which has been

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recorded by other observers also, suggests that the first attempts at
speech represent an inheritance rather than an acquirement.

To the general teaching of the book only praise can be given. There
is, possibly, a certain quaintness about the proposition that a baby may
be too old at five, but the point made is a good one. In regard to the
education of children we are still far from the happy mean, and the
influence of fashion on methods of teaching is not helpful. It is
certainly much better to lets one’s pig trot to market rather than to
have to haul him there by the hind leg, but he must be supervised
sufficiently closely to prevent his bolting down the side streets, and the
complacent parent who justifies his neglect by the fatuous excuse that
“ you can’t put old heads on young shoulders,” is just as dangerous to
a child’s mental development as ever was the bigoted pedagogue of the
past. E. B. S.

Fart III.—Epitome of Current Literature.

1. Psycho-pathology.

The Psychology of the Normal Woman in Relation to her Crimes and
Passions: Her Peculiar Psychoses [La Psicologia della Donna
Normale in relazione ai suoi Delitti e alle Passioni: Psicosi sue
peculiar *]. (Arch, di Antropol. Crim. Psich. e Med. Leg., Sept.-
Dee., 1917.) Lombroso, G.

It has been frequently observed that crimes committed by women
are usually of comparatively small importance, and that murder is
rarely committed by them. On the other hand, they have been known
to have become suddenly insane or to have committed atrocious crimes
from causes which were strangely disproportionate to the results. The
writer attributes these particular forms of criminality and insanity to
woman’s special emotionalism (passionalith), and the illogicality, exaggera¬
tion, easy vivification of inanimate objects, ideas of the importance of
dress, and enormous amourpropre which are derived from it.

Feminine emotionalism is distinguished from the masculine by the
fact that it always has for an object a living, concrete being—a father,
husband, lover, child, or even a dog or a cat. A woman is miserable
unless she has something to which she can dedicate herself, for which
she can make real sacrifices. This feminine altruism is necessary for
the preservation of the species. If the female were not provided with
it, the species would presently be extinguished. This ardent passion
for every living thing, which potential maternity develops in a woman,
is the primary cause of her minor criminality. She receives such pleasure
from the life around her that she has a profound repugnance to
destroy it.

One of the primary consequences, if not the cause, of the special
emotionalism of woman is her lack of logic. A woman is devoted to
others from instinct and impulse, not from reflection. This want of

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logic explains how crimes committed by women are often so absurd
and fantastic. A female criminal only exaggerates in crime a character
which is hers normally.

Another characteristic derived from the emotionalism of women, and
which reveals itself perhaps more in their suicides and psychoses than
in their crimes, is exaggeration. It is the cause of a woman’s irritability,
susceptibility and illusions. When life is tranquil a man simply enjoys
it without worrying about the past or future. But a woman does not
live in the present; she lives in the past or future, and is continually
tormenting herself about what may or may not happen. Before a girl
is married she is thinking of the evils which may befall her children.
When she is married and has a perfectly healthy child, she torments
herself about what would happen if he were to fall ill.

Women are endowed with an imagination which appears to have the
power of transforming the inanimate objects around them into living
beings, in which they confide, and which they love as real persons.
Mrs. Browning, George Sand, Juliette Lambert and Laura Thompson
spoke to the trees in their gardens, and in their letters they show that
they believed that the trees were sensible of their affection. This
power, which a woman has of vivifying the inanimate things around her
and of loving them as living beings, explains the passion with which
she resists those who would deprive her of them, and one understands
how it may lead her to falsehood and theft to preserve them, and even
cause her to murder without repugnance those who would take them
away from her. This feminine love for inanimate objects led Cesare
Lombroso to suggest more than once that the furniture should legally
belong to the wife.

The writer says that vanity has but little to do with a woman’s love
of dress. According to him, dress, ornaments, jewels are for a woman
the marks which demonstrate to the public, which does not know her,
her social class, her riches, the affection of her husband and relatives.
One observes that a middle-class woman displays all her luxury in the
street or in the theatre where the public, whose judgment is important
to her, looks at her and judges her; while the high-born lady dresses
modestly for the street, and reserves her elegant attire for the drawing
room or the dining room, where she finds the public whose approbation
she desires. A jewel or a beautiful dress is to a woman what a cross is
to a chevalier, or a medal to a soldier; they represent her rank. The
fact that dress represents so much to a woman explains how she will
often steal or commit other crimes in order to possess an ornament or
a beautiful garment.

Women attach enormous importance to the judgment of others.
This sentiment, improperly called amour propre , often induces them to
risk personal injury rather than expose themselves to the disapprobation,
the sarcasm or the compassion of others. This is the reason for the
greater number of infanticides and of many other crimes such as the
murder of a lover who abandons or betrays his sweetheart. A woman
never kills the husband who betrays or abandons her, but she frequently
murders the lover who does so, because the last offends her amour
propre , and the first offends only her love.

J. Barfield Adams.

LXVI. 12

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Attempted Suicide among Soldiers [ 7 / Tentato Suicidio nei Militari],

(Arch, di Antropol. Crim. Psich. e Med. Leg., Sept.-Dee ., 1917.)

Lattes , L.

It has been observed that the method of suicide generally adopted
by men is by fire-arms, that by hanging being the next favourite, while
drowning and poison, methods usually preferred by women, are more
rarely employed. The 60 cases of attempted suicide among soldiers
studied by the writer gave the following results: drowning 15,
poison 14, precipitation from a height 11, hanging 9, with cutting
weapons 6, with fire-arms 4, suffocation 1.

It may appear strange that soldiers, who are provided with fire-arms,
should so rarely make use of them. But the writer points out that a
civilian usually attempts to kill himself with a revolver, while a soldier
has only at his disposal a rifle, which is not altogether a convenient
weapon for self-destruction, especially when it is necessary to elude the
observation of numerous comrades. Further, the majority of suicides
among soldiers are attempted by men who have already exhibited signs
of mental disturbance, are under observation, and have been deprived
of dangerous weapons. This latter reason probably accounts for the
frequency of such methods as precipitation from a height and drowning,
which do not require any instruments, and are easy to accomplish
unexpectedly when surveillance has been eluded.

The large percentage of cases of drowning might give rise to the
suspicion that some of these attempts were simulated suicides.
Drowning is a method which permits the shamming of the intention of
committing suicide with the least risk and the least pain. But the
writer is of the opinion that the cases under his observation were
genuine attempts.

The attempt of suicide was always the prescient manifestation of a
permanent or transitory state of depression or delirium. It was
attempted without motive, and was the manifestation of automatism in
a state of cloudy consciousness. This was verified constantly in cases
of hanging, suffocation, precipitation from a height, or the use of fire¬
arms—modes of self-destruction which do not give rise to the suspicion
of simulation. In some cases of drowning and of poisoning there was
melancholic depression with a permanent tendency to suicide.

In other cases of all methods one did not meet with permanent
psychical symptoms suggesting suicide, although one could not admit
mental integrity. These patients were degenerates with a bad heredity,
morally insensible, inamenable to discipline, pathologically impulsive,
and a prey to passionate crises. In these cases the act had not the
deliberate aim of freeing the man from the weight of life. It was the result
of impulse—a reaction against provocation, annoyance or fear. Often
the attempt was made after a simple reprimand or punishment, or
immediately after a man joined his regiment or arrived at the front.
Sometimes it was because a man did not obtain a desired reward or a
convalescent leave of absence. In one case the cause was a quarrel
with a comrade; in two, amorous impulses (one being a case of homo¬
sexuality) ; in one, an unjust imputation of theft; in another a deserter
attempted to commit suicide on the arrival of the carabinieri to arrest
him.

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Dr. Lattes’ paper includes detailed reports of the sixty cases, which,
though very condensed, are remarkably clear pictures of the mental
condition of each patient. A few of the cases give rise to suspicions of
simulation and malingering, but the majority were evidently genuine
attempts at suicide. J. Barfield Adams.

2. /Etiology.

Syphilis as an ^Etiological Factor in Epilepsy. ( Journ. Missouri Stale
Med. Soc., November , 1919.) Booth , D. S.

The author prefaces his thesis by defining epilepsy on the basis of
entity, though calling attention to the fact that it is but a syndrome
resulting from many and various conditions, some known and discover¬
able by a thorough and complete clinical and laboratory examination,
others unknown and not discoverable even post-mortem by any means
yet known—so-called idiopathic epilepsy.

The author recalls that there is a variation between different observers
as to the frequency of syphilis as an setiological factor in epilepsy, at
least to the degree that it is the sole cause—which is often difficult, and
at times impossible, to demonstrate. Though generally recognised that
epilepsy may be caused by various tangible syphilitic demonstrations,
most authors do not mention the possibility of syphilis causing a
“ basic impairment of the germ-plasm ” without pathological findings;
however, it appears evident that there must be a peculiar condition of
the nervous system, inherited or acquired, that enables an irritant,
whether toxic or otherwise, to produce stereotyped attacks in certain
individuals and not in all having a similar exciting factor.

Most text-books merely refer to syphilis as one of the causes of
epileptic attacks without any reference as to its frequence or the manner
in which it acts.

Available statistics give syphilis as infrequent in epileptics—from 5 to
14 per cent. —while reports of most serologists give a small percentage of
positive Wassermann reactions in both the blood and spinal fluid, with
variable and inconstant findings in the latter as to pressure, pleocytosis
and globulin content, though frequently there is a considerable devia¬
tion from the normal reaction of the Lange colloidal gold test.

If it be possible for syphilis to be present in an epileptic without
giving any diagnostic evidence, it may be argued that the disease should
at any rate respond to antiluetic treatment, which is untenable, since a
disease or condition is not necessarily cured by treatment directed to
the cause; hence the fact that symptoms, presumably due to a frank
syphilis, do not recover after all clinical and serological evidence of
syphilis has disappeared, does not necessarily argue against a syphilitic
origin.

Another source of error arises from depending too much upon the
laboratory findings and too little upon the findings of a critical clinical
examination.

Though some of the author’s cases of epilepsy have shown only a
two-plus Wassermann and a few but a one-plus reaction, he is treating
them as though specific in origin with encouraging results, though it is

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too early to record conclusions. Those giving a one-plus Wassermann
have been almost entirely children or women, in whom he had reason
to believe that if syphilis were present at all it was hereditary.

While unprepared at this time to give data, the author states that in
his experience of the past several years the proportion of epileptics
giving a Wassermann reaction in some degree is much greater than
that given in available statistics, and he feels confident that the
laboratory has not detected all cases in which syphilis was, either
directly or indirectly, an aetiological factor. Author’s Abstract.

3. Clinical Psychiatry.

A Contribution to the Study of Toxicomania . . . on a Psychasthenic

Foundation (. Psycho-toxicomania) [Contributo alio Studio delle
Tossicomanie . . . su Fondo Psicastenico ( Psico-tossicomanie)\

{Reprinted from II Manicomio, 1918.) Bianchini, L.

R. F. E—, a sub-lieutenant of infantry, was charged with cowardice
for having on November 1st, 1916, at the commencement of an attack
on the enemy’s position, deserted his company. The regimental surgeon
reported that the man was a confirmed morphia maniac, and that scars
of injections were visible on his body. The commander of his battalion
reported that he was intelligent, capable of service, but of a rather weak
physical constitution. The captain of his company reported that he
was ignorant of moral duties, had no sentiment of dignity or amour
profre , that he was a morphia maniac, and gave one the impression that
he was mad.

R. F. E— was the eldest and the least robust of a family of six, the
family history being good. At school and afterwards he showed himself
fairly intelligent, but his intelligence was ill-balanced and his will was
weak. He was also very vain.

He commenced smoking tobacco at the age of fourteen, and he gave
himself so completely up to the habit that at eighteen he was accustomed
to smoke 100 cigarettes a day.

He did not choose to follow the public course of lectures, but
preferred studying at home for his licentiate. He worked hard, but
bis labour was so vacillating and so badly directed that he failed to pass
the examination. He was a great reader, but his reading was desultory.
He appears to have found more pleasure in the study-of chemistry than
in any other branch of knowledge. The description of the effects of
certain alkaloids on man and animals fascinated him. He read many
books on pharmacology and toxicology. He obtained specimens of
various drugs, such as chloroform, chloral, Indian hemp, opium, morphia,
atropia, cocaine, etc., with which he experimented on himself. He made
the first injection of cocaine in August, 1914, when he was eighteen
years and six months old. It appears, therefore, that he became a
toxicomaniac from curiosity. But it is to be noted that in his own
confession he speaks of having been induced to smoke opium by a
friend who had frequented the opium dens of Marseilles and Paris.

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When the war broke out he enrolled himself in a regimental course
for officer students at Turin. Here he continued the use of cocaine
and morphia. Having completed the course from which he came out
as sub-lieutenant in July, 1915, he was appointed instructor to a squad
of officer students. Although he was saturated with poison, the sudden
change in bis life, pride in his appointment and consciousness of
responsibility made him spontaneously and with little suffering give up
the injections. He appears to have almost succeeded in breaking off
the habit.

He passed in due time to the Front, fought bravely, and was wounded
on September 28th, 1915. He was sent to the hospital at Pavia. Here
he took up his old habits, and continued them when he was sent home
on leave. He now used morphia and cocaine together. He injected
the morphia first, left the needle in the skin, filled the syringe with the
solution of cocaine, and completed the operation. He used large doses
of both drugs. The injections were made in the afternoon, evening
and night, never in the morning. No one except a doctor at Pavia,
who spoke strongly to him on the subject, appears to have suspected
the habit.

After his convalescent leave was ended he passed to the depot as
instructor until the end of May. During the last month, becoming
acting captain, pride again induced him to give up his vicious habit.
Being sent to the Trentino, he fought bravely. For a whole month he
left off the use of the alkaloids, only masticating a quantity of leaves of
Bolivian coca. His regiment being sent to rest at Vicenza, he resumed
his evil habits, using large quantities of morphia and cocaine.

In August his regiment was sent to the Carso. He was now
beginning to show signs of mental and bodily enfeeblement. Finally
he ran short of morphia, which he had been using in large doses, and
when the regiment went into action on November 1st he had been
forty-eight hours without an injection. He advanced bravely to the
attack, but the morphia hunger overcame his physical and moral
strength. He deserted his post, and after wandering aimlessly for three
days he found his way, ill and broken down, to the hospital of his
army corps.

Prof. Bianchini draws attention to the following points :

(1) The age of the patient is exceptional. He was aet. 18. It is
rare to meet with a toxicomaniac under twenty-five.

(2) With classical toxicomaniacs the need of the poison, even from
the beginning, is constant, continued, and progressively increasing.
In this case the need was sporadic, discontinued and non-progressive.
In the case of a classical toxicomaniac voluntary suspension of the use
of the drug is almost impossible; in this case it was effected spon¬
taneously under certain circumstances and with comparatively little
suffering.

(3) In this case the injections were made in the afternoon, evening
or night, never in the morning. The morphia maniac, on the other
hand, deprived of the poison for some hours and exhausted from want
of sleep, must make the injections in the morning to refresh himself as
an alcoholic drinks to stop his morning tremors. And it is necessary
for him, like the alcoholic, to continue the use of the drug all through

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the day without measure or method, until in the evening he desists
because his organism is saturated.

(4) The large doses employed by the patient.

(5) The use of morphia and cocaine together. The morphia maniac
rarely uses the two drugs because he is aware of their antagonism. If
he uses the second it is because he is in want of the first or is in search
of new sensations. He is always a monotoxico-raaniac. He may
casually employ other poisons, but he finishes by giving preference
to one, of which he becomes the absolute slave.

J. Barfield Adams.

The Influence of Alcohol in the Production of Hallucinations in General
Paralysis of the Insane. (Joum. Nero, and Ment. Dis., April,
1919.) Immermann , S. L.

The frequency of hallucinations in general paralysis has been much
disputed, some authors stating they are common, others rare. Imraer-
mann’s study was undertaken to determine, if possible, what relation
alcoholism has to hallucinations in paresis. Several theories have been
advanced to account for the occurrence of hallucinations in paretics r
(1) The anatomical theory. (2) The theory of the previous personality
of the patient. This supposes that a paretic who is not merely demented
is suffering from a psychosis in addition to his paresis. (3) The toxic
theory. (4) The psychogenic theory. This possible source has not
been investigated in this study.

Innermann in his 73 cases found 21 patients to be hallucinated—
11 visual, 10 auditory—and 52 patients to be non-hallucinated. He
divides these groups into sub-groups and gives a table showing the
percentages to alcoholism in each sub-group. His conclusions are
summed up as follows: “ (1) In a study of seventy-three paretics the-
patients were found to fall into several clinical groups, which tended
to remain fairly distinct. (2) Hallucinations were found to occur in
certain of these groups and tended to remain confined to these groups.
(3) Excessive alcoholism occurred in only some of the hallucinatory
groups, and was at most an indirect factor in the production of the
hallucinations. (4) Certain manic types showed hallucinations and a
high incidence of excess of alcoholic use, abnormal make-up and absent
knee-jerks, but other hallucinatory patients did not show this com¬
bination.” C. W. Forsyth.

Simulation ( Malingering) not an Adequate Diagnosis. ( fourn. Nero,
and Ment. Dis., September, 1919.) White, W. A.

The writer would confine the conception of simulation (malingering)
to cases where the symptom can be shown to have its origin in the
field of clear conscious awareness of the individual, who at the same
time has the conscious purpose in mind to deceive, to avoid responsi¬
bility or to escape punishment. The diagnosis of malingering is not
an adequate one as we have no right to diagnose from a single symptom.
Experienced psychiatrists look upon simulation per se as a relatively
unusual phenomenon, and see in the simulator an individual with bad
personality make-up and in the symptom an expression of such defect

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it is the individual’s reaction—his way of meeting a problem presented
to him by reality. His reaction is an indication of a defective per¬
sonality.

The usual attitude of the herd towards the malingerer is one of
condemnation: he deserves punishment. Punishment is useful for
the purpose of reinforcing the repression and is to that extent valuable,
but for the individual the punishment should have nothing of hate
in it. It should be devised with the sole idea of changing the type
of reaction from an antisocial form to a socially acceptable one—that is,
an attempt ought to be made to sublimate the instinctive antisocial
expression. This is only possible by the sympathetic understanding
of the conflict and of the reaction of each individual.

C. W. Forsyth.

An Acute Prison Neurosis of the Anxiety Type, (fount. Nero, and
Ment. Dis., October , 1919.) Yawger, N. S.

Gleuck has well shown that the criminal occasionally develops a
psychosis as the result of his confinement in prison on the top of a
psychopathic personality. The writer has, however, found that occa¬
sionally an anxiety neurosis is manifested. About one-third of the
convicts coming up for pardon or parole show nervousness to a greater
or less extent—the criminals refer to it as “ pardonitis ” or “parolitis”;
the ones who escape the disorder appear to be those who expect
favourable conditions to await them on their discharge. An account
of the symptoms is given; they do not differ from those found in
anxiety neurosis in life outside the prisons.

Yawger considers that the condition is the result of important
factors aside from the sexual sphere. Some prisoners fear that they
may not be released; a few know that detainers will be lodged against
them and that they will be rearrested on discharge; in others—the
majority—the anxiety neurosis is determined by the thought that when
released they may be homeless and that they will be unwelcome
members of society. C. W. Forsyth.

4. Treatment of Insanity.

The Problems of Pulmonary Tuberculosis in a Psychiatric Hospital,
(fount. Nerv. and Ment. Dis., fanuary , 1919.) Silk, S. A.

This paper emphasises the importance of the tubercular problem in
mental hospitals. Patients will be admitted suffering from this disease
and other patients will develop it later. The duty of every hospital
will be to cure as many cases as possible and to prevent the spread of
the disease amongst non-tubercular patients. As regards general con¬
ditions, the construction of the hospital should be carried out on up-
to-date hygienic lines, allowance being made for the maximum available
amount of sunshine, light and fresh air at all times. Large porches
or enclosed parts should be used for ambulant patients, the ventilation
of wards and dormitories should be thorough, and in winter extra
blankets should be used {instead of keeping out fresh air by closing
windows. The food supplied should be wholesome and varied.

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EPITOME.

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To reduce the occurrence of tuberculosis and arrest the disease a
systematic procedure is necessary. Specially constructed tuberculosis
cottages accommodating 3 per cent, of the population are required, and
in addition a large ward (the “preventorium ”) surrounded by porches
for suspicious cases who do not cough or expectorate. As soon as a
case is diagnosed as suffering from active tuberculosis it should be
transferred to the tuberculosis cottage, but if the disease becomes
arrested it should be transferred back to the “ preventorium ” first, and
later sent back to the general ward or to the tuberculosis cottage as
conditions direct. The routine followed in the tuberculosis department
consists in giving patients additional food, as milk and eggs, at fixed
times between meals, and in rest or the avoidance of strenuous work.
A thorough examination of patients in the “ preventorium ” should take
place at least once monthly, weighing weekly, and the pulse, respiration
and temperature charted twice daily and cough and expectoration
noted. The management of the tuberculosis department should be
under a specially-trained physician, or if impracticable, it should be
entrusted to a member of the staff who is best fitted for the work.
The staff nurses in this department should not be transferred to
ordinary wards. The co-operation of physicians in charge of general
wards is necessary, as they are in contact with the cases in the earliest
stages of the disease, when removal to the tuberculosis department can
be a help both as regards cure and the prevention of the spread of the
disease. Special attention should be paid to dementia prsecox cases as
they are very vulnerable to tuberculosis. In order that an early diag¬
nosis of tuberculosis may be made the following rules should be
observed:

(1) A thorough initial physical examination; (2) the weight of every
patient noted on admission and at regular intervals thereafter; (3)
persistent cough or expectoration should be reported to the physician;
(4) a full history should be elicited if possible; (5) all cases showing
symptoms of tuberculosis should be carefully examined.

F. E. Stokes.

5. Pathology of Insanity.

The Correlation between Mental Defects and Anomalies of the Hard
Palate. ( Amer. Journ. of Insanity, April , 1919.) Case, Irene.

This investigation was carried out in the Psychopathic Laboratory of
the University of Chicago, on the casts of the palate of forty-six normal
and abnormal children brought to the laboratory, and is an attempt to
test the doctrine, taught for over three centuries, that a deformed
palate is frequently found in the feeble-minded. Is it really true, the
author inquires, that a defective palate indicates a defective mentality ?

The cases seem too few for assured results, but the examination was
elaborate, and the measurements of the palate were considered in
relation to the measurements of the head and to the “ mental age ” of
the subject. The author’s main contention is that the size of the
palate is correlated with the size and shape of the head. The abnormal
palate varies more than the normal simply because the head varies

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more in size and shape in abnormal than in normal individuals. In
general two types of palate were noted : (t) High and narrow, associated
with a dolichocephalic head; (2) low and broad, associated with a
brachycephalic head. Thus the head form determines the palate form,
and either of the two forms may be normal. There is no necessary
connection between a low mental capacity and a high palate. The
female palate is smaller than the male, except as regards height; this
depends on a general tendency for small heads to have high palates.
As for asymmetry, the normal individuals showed it as generally as the
abnormal and sometimes to as marked a degree.

Havelock Ellis.

Notes on the Relation of Tuberculosis to Dementia Prcecox. (Journ.

Nero, and Ment. Dis., September , 1918.) Southard, E, E, and

Cameron , M. M.

The statistics used for this study were obtained from the autopsy
series of the Massachusetts Institution for the Insane. Of 5,040
autopsies there were 403 cases of dementia praecox, of whom 301 died
of proved and 15 of doubtful tuberculosis, and 339 cases of manic-
depressive psychosis, of whom 224 died of proved and 20 of
doubtful tuberculosis. There were 87 cases of dementia praecox
and 95 cases of manic-depressive psychosis who showed no signs of
tuberculosis postmortem. In this group of dementia praecox cases the
tuberculosis hypothesis could not be raised as to aetiology on any
anatomical grounds. It is possible that these non-tubercular cases
were incorrectly diagnosed ? To test this hypothesis the symptomatology
of non-selected cases from the Danvers collection was examined.
These cases of dementia praecox were divided into two groups: (r)
Tubercular, (2) non-tubercular—proved so post-mortem —there being
36 of the former and 27 of the latter. The tubercular as compared
with the non-tubercular cases were equally subject to dementia and
to delusions of persecution, were more apt to be resistive, violent, and
subject to psychomotor excitement, were more suicidal, manneristic,
disorientated and confused, and slightly more subject to delusions
involving personality; the non-tubercular cases were more apt to be
peripherally restless, mute, refuse food, and be subject to somatic
delusions. Can it be that tuberculosis supervening in dementia praecox
directs the symptoms more towards catatonia and to hyperkinetic
symptoms presumably of a psychogenetic or central nature, and less
to peripheral forms of hyperkinesis, and may tuberculosis cause a
trend of symptoms towards the manic-depressive psychosis ?

F. E. Stokes.

6 . Sociology.

Psychiatry as an Aid to Industrial Efficiency. ( Amer . Journ. of
Insanity , April , 1919.) Bell , fu Don.

The psychiatrist who realises the changed conditions of the times and
the urgency which labour and economic conditions are to-day assuming
may sometimes ask himself where he comes in. Dr. Bell attempts to

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help him in answering this question, basing his conclusions on the
results of visits to large industrial plants in various parts of America,
interviews with managers and men, and much detailed study of indi¬
vidual workmen. He believes in close relationship between employer
and employee and the stabilisation of industry by practical scientific
selection of human material, creating trust, confidence and co-operation.
To this end it is necessary to study the individual as to his physical,
nervous and mental fitness for his job, and to ascertain his special
abilities and disabilities. Prophylactic measures adopted now, with
the sympathetic co-operation of labour and industrial leaders, will
prevent the disease of inefficiency from making further inroads upon
either capital or labour, stabilising and unifying both. The present
industrial research—not only scientific in aim, but practically humane
and economic—is the preliminary stage of a work which, the author
believes, has not previously been attempted.

The chief part of this paper deals with methods of procedure and
schedules. The methods include (1) general medical, (2) neurological,
(3) psychiatrical, (4) psychological, and (5) social, since the scheme
involves the co-ordination of all scientific aids in industrial examina¬
tions. Such a scheme could be put into operation in the employment
bureau of industrial organisation, and also used to ascertain the
physical, nervous and mental equipment of workers already employed.

As an example, the results of an examination of fifty-seven employees
of an industrial company is presented shortly before a strike occurred.
All the strikers were found to have something wrong with them from a
nervous or mental standpoint, nearly all having a psychopathic history.
Such an examination, it is claimed, is of value in predetermining
conduct and enabling the employer to remedy conditions likely to
cause trouble.

The author concludes that it is desirable, even from an economic
point of view, to establish medico-psychological laboratories as the
principal department of employment bureaus of every large industrial
organisation, and further advocates the establishment of a central
employment clearing-house with medico-psychological laboratory to
act for groups of industrial organisations too small to economically
conduct their own bureaus. There should be a representation of
labour in all such bureaus, which would react to the benefit alike of the
individual, the industrial organisation, the labour organisation and the
community. Havelock Ellis.

7. Mental Hospital Reports, 1918-19.

Report on Lebanon Hospital, 1918-19.

The Twentieth Report, covering 1918-19, is an extraordinarily inter¬
esting one, and it gives a clear account of the good work done at this
international asylum. It also points out the great amount of tact that
was exhibited by Dr. Watson Smith. In fact, it is almost like a romance
to find that, of all institutions, hospitals and the like that had been
under the control of Europeans, it was the only one that was not seized
upon by the Turks and altogether upset. On several occasions there

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were missions from Turks with the idea of taking over the place and
of replacing the doctor there, but by the exercise of an extraordinary
amount of tact he was able to get the Turks to recognise that it was not
an English institution, but was a benevolent institution, by which the
Turks gained as much as did Europeans. So that, even when thousands
were dying in the neighbourhood of starvation, the hospital was able to
get a steady supply of flour. There was a time when the assistance of
the United States was very useful to the institution.

For two years during the war Dr. Watson Smith practically never left
the building : it was not safe for him to do so, as he might easily have
been deported. Fortunately, since then he has been able to leave his
work and get a rest, the while he is acting as propagandist in Europe
and America. And we trust that when he returns to his arduous task
he will be encouraged by the support that he has gained in these two
countries.

Not only was the asylum used for the ordinary patients, but the
Turks themselves removed a considerable number of patients who were
certainly in a very distressed and distressful condition from Damascus:
and later on it was utilised for the soldiers of the Allied forces.

During the war Dr. Watson Smith had very great difficulties to con¬
tend with, such as difficulties with the authorities in getting food. And,
without going into details, I may say that, one way and another, he
managed to surmount them all and was able to keep on good terms
with the Turkish authorities, so they gave him much less trouble than
was given to the administrations of other foreign institutions. It is
quite certain that admirable work is being done, and that all praise is
due to Dr. Watson Smith. There is no doubt that, as in Egypt, there
is a very great want of further development and further accommodation,
and as this Lebanon Hospital is international and receives considerable
support not only from England and America but also from other
countries, such as Switzerland, one feels confident that a great future is
before it. George H. Savage.

Lunacy in Egypt, 1918.

Once more we have to note the receipt of the annual report of Drs.
Wamock and Dudgeon, and once more we have to speak of it as a
model of what such reports should be. During the year Dr. Wamock
had a much-needed holiday and his place was filled by his deputy, Dr.
Dudgeon.

The chief points only can be extracted from the report for every page
is noteworthy. The usual overcrowding at both asylums occurred, with
the inevitable result that many patients had to be sent away when only
convalescent, and many of these relapsed and many were readmitted as
criminals.

Dr. Warnock points out the need for several more asylums; there
should certainly be one near Alexandria and a special one for the male
criminal lunatics, who, at presept, have to be placed in the Cairo asylum
of Abbasiya. Besides these there should be receiving homes, for though
a fair proportion of the cases pass through local hospitals no special
provision is made for them. The usual difficulty about a suitable staff

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was accentuated, for many were called up for military duties. The
medical instruction connected with the Egyptian School of Medicine was
continued.

In addition to the local cases provision had to be made for soldiers
connected with the British Army. This was managed by taking over
the house of the former Assistant Medical Officer.

There was nothing very special about the cases, though it seemed a
large proportion were defectives who ought never to have been enlisted
and certainly not sent abroad. A table is given of the nature of the
cases ; very few deaths occurred, but few of the patients were long resident,
being sent out of Egypt as soon as possible. Carefully arranged
tables are given of the patients who were received as criminals and the
various crimes for which they were under treatment, also the supposed
causes of the mental disorder. Here it is noteworthy that pellagra
played a very important part; crimes of violence were common. It
certainly is one of the blots on the Egyptian Government that the
criminals and lunatics are herded together, though, as Dr. Wamock
points out, he separates them as much as possible. A fair proportion
of general paralytics were admitted and quite a large proportion of
these were women. Wassermann reaction proved positive in most but
not in all of the cases. The examination was conducted in the Govern¬
ment Laboratory and is therefore to be trusted. Besides the general
paralytics a large number of other patients were examined and a very
large number, especially of the pellagrous cases, proved positive. This
is noteworthy. The diet was to a considerable extent modified during
the war and a careful study of the dietary was made in relation to the
pellagra.

Prof. Wilson, of the Government Health Department, advised on this
and caused modification of the diet making up for the deficiencies, but
with all the treatment the disease when once establised is believed by
Dr. Dudgeon to be incurable. He tried all sorts of remedies for the
various symptoms, and though remissions did occur the disease returned.

The death-rate was high, but this was partly due to bad diet and
partly to the gradual accumulation of old and chronic cases. Post¬
mortems were frequently made and scientific work would have been
carried out if the staff had not been shorthanded.

The tables giving the local incidence of insanity are of only local
interest, but one has to notice that the general paralytics come most
from Cairo and cities while the pellagrous come largely from the
provinces. The details of the cost and the modification in the building
are given.

As to treatment sedatives were not given to any extent and practically
no restraint was used; very few accidents of any kind are recorded.

We must extend our sympathy to the doctors and their families
because the disturbed state of the country has rendered their lives irk¬
some and even dangerous.

Dr. Dudgeon gives a special and interesting account of the work
done at Khanki. He receives chiefly the provincial patients direct but
also a proportion of the chronic cases from Cairo. His asylum is
of course new and growing. It was always more than full and for a
time he bad water and other difficulties, but he has done great

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things in converting a desert into an oasis. He provides vegetables
for his own and for the parent institution and makes the farm remune¬
rative. Gradually means of approach to Cairo are improving so that
the asylum is not so isolated as it was. Excellent tables are given and
much information about pellagra and its symptoms are collected; here is,
n too, an interesting table as to the result of examination of the faeces of
a large series of cases and a list of the prevalent parasites is given.
Influenza was a source of trouble but was not as fatal as might have
been expected.

We feel that the report should be more generally seen, and we are
sure that the English alienists have reason to be proud of the work of
their Egyptian colleagues. George H. Savage.

Part IV.—Notes and News.

MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN

AND IRELAND.

Thb Ordinary Quarterly Meeting of the Association was held at the
Medical Society’s Rooms, No. ii, Chandos Street, W. 1, on Tuesday, February
24th, 1920, Dr. Bedford Pierce (President) in the chair.

Members present; Dr. Bedford Pierce (President), Major R. Worth (General
Secretary), Sir R. Armstrong-Jones, Sir F. W. Mott, Drs. H. Baird, G. F. Barham,

F. Beach, C. W. Bower, D. Bower, A. Helen Boyle, J. Chambers, G. Clarke,
R. H. Cole, P. C. Coombes, H. Corner, M. Craig, A. W. Daniel, J. F. Dixon, R.
Eager, J. H. Earls, H. Eggleston, S. C. Elgee, A. E. Evans, S. J. Gilfillan, H. E.
Haynes, R. D. Hotchkis, D. Hunter, G. H. Johnston, M. H. Johnston, J. Keay,
K. S. Littlejohn, J. R. Lord, J. A. Lowry, W. F. Menzies, J. Middlemass, A. Miller,
D. Nicholson, D. Ogilvy, E. S. Pasmore, N. R. Phillips, D. Ross, G. E. Shuttleworth,
J. H. Skeen, G. W. Smith, R. P. Smith, J. Q. Soutar, J. B. Spence, R. H. Steen,
J. Stewart, R. C. Stewart, F. R. P. Taylor, D, G. Thomson, E. Barton White, H.
Wolseley- Lewis.

Members present at the Council Meeting: Drs. Bedford Pierce (President),
R. Worth (General Secretary), D. Bower, A. Helen Boyle, J. Chambers, R. H.
Cole, M. Craig, A. Daniel, R. Eager, R. D. Hotchkis, J. Keay, J. R. Lord,
H. C. MacBryan, T. C. Mackenzie, W. F. Menzies, A. Miller, J. Noel Sergeant,

G. E. Shuttleworth, J. H. Skeen, R. H. Steen, D. G. Thomson and H. Wolseley*
Lewis.

Apologies were received from Profs. Obersteiner (Vienna) and Emil Kraepelin
(Munich), and Drs. L. R. Oswald, G. Douglas McRae, J. P. Westrupp, J. Mills,
D. A. Pilcz (Vienna), J. Whitwell, R. B. Campbell, T. Stewart Adair, G. M.
Robertson and J. N. Greene Nolan.

The minutes of the last meeting, having already been printed and circulated in
the journal, were taken as read and were duly confirmed.

Matters arising from the Council Meeting.

The President said the next item concerned business which arose out of the
Council meeting just held. He asked Major Worth to refer to the appointment of
a Handbook Committee.

Major Worth (Secretary) said the following members had been approached to
form themselves into a Committee charged with the revision of the Handbook,
under the style " The Editorial Handbook Committee ”: Representing England—
Dr. Bedford Pierce, Dr. Middlemass and Dr. Rees Thomas; representing
Scotland—Dr. Mackenzie, Dr. Donald Ross and Dr. George M. Robertson;
representing Ireland—Dr. Rutherford and Dr. Nolan. Ail these gentlemen had
expressed their willingness, and steps were being taken to call them together.

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The other matter arose from certain correspondence he had had with the
National Asylum Workers’ Union. Probably members were aware that that
Union was taking steps to bring before Parliament some amendments of the
Asylum Officers' Superannuation Act, 1909. He also had been in correspondence
with the Clerks’, Stewards’ and Storekeepers’ Association, on the same subject,
and it had been decided that a conference should be held, consisting of four
members of the Union, two members of the Clerks’, Stewards and Storekeepers’
Association, and two members of our Association. As representatives of our
Association Dr. David Thomson and himself had been chosen, their function
being chiefly to hold a watching brief, because, at the moment, they had no
definite mandate.

The President said there was one other matter which came forward from
the Council meeting. The Asylum Workers’ Association had a small fund for
the benefit of nurses who were sick, the amount of the fund being about £80, and
they had invited this Association to administer that fund when the Asylum
Workers’ Association shall have closed down finally. At that morning’s Council
meeting it was decided to accede to that request. The Secretary and Treasurer,
with Dr. Shuttleworth and Dr. Powell, were appointed to act as a small Committee
to deal with cases as they arose.

Another subject which was discussed by the Council, and which he brought
before the meeting, was one arising out of a letter which had been received
pointing out the serious and grave hardship many old asylum workers were under
owing to the depreciation in the value of money, and it was thought it would be
proper for this Association to draw attention to the matter. It did not require
any speech to justify it. A pension which was no more than modest when granted
was very meagre indeed at present value of a sovereign. With the approval of
this Association, it had been suggested that he, the Secretary and Dr. Miller,
jointly, should write a letter on behalf of this Association, pointing out the serious
hardship accruing to many old asylum servants through the depreciation in the
value of their superannuation allowance, and that this letter be sent to the Prime
Minister, the Minister for Pensions, the Minister of Health, and the Secretary
of the Hospitals’ Association, and such others as were likely to be influenced by
the communication. He asked if any had observations to make.

Sir Robert Arm strong-Jones said he did not think it would be possible to
alter the amount of the pensions, as they had been granted according to law, and
10 change it a new law would be required.

Lt.-Col. Lord said that this was understood, and the idea was that a change in
the law should be advocated.

Dr. Dixon said he thought the difficulty was that the same question arose
regarding old pensioners of the army and navy.

The President said that this communication would only refer to the matters of
which we had definite information, although, of course, it raised a much wider issue.

The meeting approved the communication being sent.

Study Facilities for Assistant Medical Officers.

Lieut.-Col. D. Thomson said members would remember that a very valuable
paper was read before the Association at the last meeting on the question of the
special education of junior medical men who took up this specialty. This was a
subject which required to be tackled and dealt with afresh, now that all were more
or less settling down to their former work, and the subject was coming forward
more definitely. He suggested that the committee, which previously dealt with
this and allied subjects in 1908 when it was first brought forward on a short paper
of his own, might be a suitable body to be reconstituted for this purpose. The
chairman on that committee had retired from active work, but he was present to¬
day. He referred to Dr. McDowall. That committee did splendid work, and
issued the report which was well known {vide p. 373, July number, 1910.— Eds.).

The President said he thought a committee should be set up to deal with the
many important aspects of this subject, such as that of study-leave.

Lieut.-Col. D. Thomson said that progress had been made, and there had now
been established a series of courses of lectures at the Maudsley Hospital. Many
junior medical officers throughout the country were eager about this matter, and
he thought this Association ought not to drop the subject after doing very good

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pioneer work. He moved that a committee of this Association be appointed to
consider the very important questions which now arose in connection with the
obtaining of the diploma in psychiatry.

The President said he would like to hear Dr. McDowall speak on the subject,
and perhaps he would second Dr. Thomson’s proposition.

Dr. McDowall seconded the motion of Lieut.-Col. Thomson.

Lieut.-Col. Lord said he hoped it would be an instruction to the committee to
go into the whole question of medical officers’ duties. The great dearth of medical
officers, and the difficulty of getting junior men from the hospitals to select
psychiatry as their life-work, was that the work was not made sufficiently attractive
quite apart from questions of pay and conditions of service generally. The
problem of the cure of insanity was the most difficult one in the whole region of
medicine, and therefore the very best brains in the profession should be attracted
and brought to bear upon it or progress would be impossible. A sound training
in scientific psychiatry was the first step, then opportunities for further study from
time to time, and the routine work to be essentially professional and not admini¬
strative, the latter being adapted to secure this.

Sir Frederick Mott said that it would be wise to include a young and junior
medical officer among those who would form the committee.

Dr. Passmore said he would like to suggest that this committee consider the
subject of quarters for married assistant medical officers. The absence of such
accommodation was a drawback in the case of those who might wish to enter
the specialty.

The President said he gathered that the burden of Col. Thomson’s motion was
the scientific training of the younger men in the specialty, the best method of
securing and encouraging effective training, to assist them in obtaining a diploma
in psychiatry, and generally promote the scientific side of the work. To intro¬
duce the other matters would complicate the reference.

Dr. Bower said one of the chief subjects Col. Thomson was interested in was
the difficulty which assistant medical officers laboured under in getting away from
their duties on study-leave. That was a matter on which there was a need of
strong recommendations by the Association, and he thought that generally com¬
mittees of asylums would need to be educated on the matter and would fall in with
any good scheme which the Association might approve.

The President replied that the first step was to appoint the committee; its con¬
stitution would come later.

The appointment of a committee was approved.

Col. Thomson said that such members of the former committee as did the spade¬
work on this subject should be re-appointed; it would be invidious for him to
mention names. He thought Col. Lord should be on it: he was in London, and
in touch with London mental hospital work. If the meeting would agree to
the appointment of the original committee, with power to add to their number,
that would save the nomination of individual members. The reference, he thought,
should be that the committee consider the whole subject. Diplomas in psychiatry
bad already been established at five Universities. He had spoken on the matter to
one or two active, ambitious young men associated with him at Thorpe, Norwich,
and they said—" Yes, it is very nice, but how can we get study-leave ” ? The
Maudsley Hospital courses were convenient for London men, but what about the
provinces ? He thought the Association should consider how the young men
joining the specialty, or those whom it was hoped would be induced to join it, best
could take advantage of the existing provisions. Details as to the provision of
married quarters concerned individual asylum committees.

The President suggested "To consider the best method and facilities for
training in psychiatry, and for the obtaining of the diplomas which exist,” should
be the reference for the committee.

Col. Thomson agreed.

After further discussion by Dr. Soutar and Dr. Bowers—

The President suggested as members of the committee Col. Thomson, Col.
Lord, Dr. T. W. McDowall, Sir Frederick Mott and Col. Rows, with power to add
to their number.

Sir Frederick Mott repeated his former suggestion.

Dr. Nicholson said Dr. Soutar would be an excellent member of this committee.

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Col. Thomson suggested that perhaps Dr. Bond would be willing to serve.

The President said Dr. Chambers was willing to serve; he hoped Dr. Bond
also would consent to do so.

Sir R. Armstrong-Tones suggested Dr. Helen Boyle.

This concluded the list.

The following were elected members of the Association :

Parnis, Henry William, M.R.C.S., L.R.C.P., A.M.O., London County
Mental Hospital, Colney Hatch, N. 11.

Proposed by Drs. Gilfillan, MacArthur and Worth.

Haynes, Horace Guy Lankester, M.R.C.S., L.R.C.P., Littleton Hall,
Brentwood, Essex.

Proposed by Drs. Sergeant, Haynes and Bower.

Shearer, Christina Hamilton, M.B., Ch.B., Visiting Physician, Lady
Chichester Hospital, ix, The Drive, Hove, Sussex.

Proposed by Sir Robert Armstrong-Jones and Drs. Helen Boyle and Percy
Smith.

Robinson, William, M.B., Ch.B., D.P.M.Leeds, Senior Assistant, Wakefield
Asylum, West Riding Asylum, Wakefield, Yorks.

Proposed by Drs. Shaw Bolton, W. Vincent and T. Stewart Adair.

Parkin, George Gray, M.B., Ch.B., Assistant Medical Officer, Cheshire
County Asylum, Parkside, Macclesfield.

Proposed by Drs. Parkin, Dove Cormac and Stewart Adair.

Heal, James Gordon Freeman, L.M.S., N. Scotia Provin. Med. Bd., 1915,
M.D., C.M., 1915, Swallows* Nest, Felixstowe.

Proposed by Drs. Gilfillan, MacArthur and Worth.

Paper.

Dr. R. Hunter Steen : "Chronic Hallucinatory Psychosis ” (vide p. 99).

The President said he thought members could congratulate themselves, also
Dr, Steen, on an exceedingly able paper, and particularly on the charming and
lucid way in which he had presented the subject. Rarely did the Society hear a
contribution which was so easy to listen to because so clearly expressed. It went
a long way towards making a successful meeting to have a subject presented in a
forcible and clear way. Dr. Steen had endeavoured in this paper to show his
colleagues a new psychosis, to make out a case for a fresh clinical entity. The
train of symptoms was one with which all psychiatrists were familiar; there was
no one in the room who had not seen patients of the type Dr. Steen had just
described, and it was to be hoped there would be a good discussion. In reference
to the definition of paranoia, and whether such cases had hallucinations as a
marked symptom, he said that some of those present would remember Dr. Percy
Smith’s Presidential Address on that subject, in which he showed that the definition
of paranoia was far from lucid and exact, and that what passed under that name
was hardly a definite clinical entity. He (Dr. Pierce) could not agree with Dr.
Steen, for he believed cases of paranoia had hallucinations, and for that reason he
was inclined to think Dr. Steen had not fully separated his malady from paranoia.

Dr. Menzies said he had never seen a case of paranoia without hallucina¬
tions of hearing, and, with all respect to Kraepelin and his school, he did not
think such existed. He did not know whether Dr. Steen had followed up
cases of the kind for twenty or twenty-five years, but they certainly become
very demented, and in the end ordinary chronic lunatics. On making a post¬
mortem examination on such one always found the usual thickening and cortical
wasting. They could not be distinguished from other chronic mental cases. It
might be that the alienist did not see the cases described by Dr. Steen, as they
did not progress, and hence did not find their way into asylums, but the kind which
did go there progressed steadily. They were called paranoics at first, and after¬
wards were known as chronic maniacs. It came once more back to the question
of all forms of insanity being but one. Everything in insanity known at present
was, more or less, only a symptom, as Clouston tried to point out many years ago.
Still, giving a name to a condition helped, and when it was discussed it could be
with a knowledge of what was meant. With regard to the anatomical point of
view he had his quarterly debate with Dr. Bolton, and he (Dr. Menzies) always
suggested that the reason why the cerebral hemispheres became so wasted and

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membranes thickened in that area was partly geographical, partly developmental;
that the spinal fluid secreted by the choroid plexuses under pathological circum¬
stances was toxic, and R was possible that might affect directly the pyramidal
cell layer of the audito-sensory and audito-psychical centres. He did not see,
however, why research into these conditions need be confined to the psychical side.
Unless the attack were conducted from the anatomical, and especially from the
chemical standpoints, there was not likely to be much progress, because, after all,
psychology only indicated certain steps on the way.

Dr. Percy Smith said the President had been good enough to refer to his (the
speaker’s) Presidential Address on paranoia. As, however, that was now some
sixteen years ago, he was entitled to have forgotten what he then wrote. He
believed he then pointed out that people who had described paranoia—many in
Germany and other countries had written on it—had referred to acute hallucinatory
paranoia and chronic hallucinatory paranoia. Included in paranoia there was
mentioned, by different authors, almost every kind of acute psychosis met with,
even acute delirious conditions, which was absurd. He did not think he said in
his address that in no cases of paranoia were there hallucinations; any assertions
of that kind he would regard as tar too sweeping. It had been the fashion of late
years to say that if a patient had hallucinations it was not a case of paranoia,
which seemed to him to be on a par with saying that in cases of paranoia there
was no emotional disturbance—a statement which was at one time current. He
believed one of the points he made in his paper referred to was to show that
cases, to which the term “ paranoia ” was properly applied, began often with
serious emotional disturbance. His view was that many cases of paranoia did have
hallucinations. He was not present to hear the first part of Dr. Steen’s paper,
therefore he did not know what the author said about the aetiology of the condi¬
tion he described; but no doubt psycho-analytical friends would say, “ Are not
these cases psychogenetic ? ” Many of the cases sounded like those in which
there was a history of exhaustion, or of a toxic condition, like that resulting from
alcohol.

The President said that before calling upon Dr. Steen to reply he would like
to ask him whether he was prepared with any suggestion as to how it was possible
for a mental conflict to produce mental dissociation. He was sorry there had not
been a fuller discussion, but probably that was because it was a subject which
members would like to think over at leisure before expressing any decided opinions.

Dr. Steen, in reply, said he was very grateful for the way in which members
had listened to his paper. In regard to the question asked by the President as
to why a conflict produced dissociation, he was sorry he was unable to give a
satisfactory answer. Still, he had no doubt that a mental conflict did produce
dissociation, especially if such conflict had been rigorously repressed; he laid stress
upon this last point. In the first case he related there was a very severe mental
conflict, which was being sternly repressed. After this had been revealed to the
patient the symptom ceased. Unfortunately he had not then time to proceed
further with the investigation; it was during the war, and his time was very fully
occupied. Therefore he did not carry out a full psycho-analysis. The symptoms
disappeared for three years, though unhappily at the end of that time the patient
returned, with the symptoms even intensified owing to the return of the conflict.
The discussion on the paper had ranged largely round the question of the similarity
of the condition he had described to paranoia. Dr. Percy Smith had said there were
hallucinations in paranoia; and he (Dr. Steen) would agree there were hallucina¬
tions in some cases of paranoia, but he wished specially to point out that paranoia
was a disease characterised by delusions, and the rule was for hallucinations
to be absent; the latter were not a characteristic feature of paranoia. On the
other hand, the cases he had described were so characterised. In the first of the
cases, for instance, a girl came to him with weeping fits, and he then discovered
she heard voices. After talking to her on three or four occasions the voices
ceased. There were no delusions. Her case was not one of paranoia as he
understood it. The second case had had hallucinations of hearing for about six
years, but there were no delusions whatever. He could not fit that case into
paranoia either. Eventually she might develop delusions—indeed, he thought
that process had already commenced. He could not call that case one of
paranoia. He had been glad to hear what Dr. Menzies said about a physical

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basis for hallucinations. In his own reading on the subject of hallucina¬
tions and their study the conception of them from a physical standpoint had
not helped him in the least. Approach from the psychical side did, however, give
him a better insight into the condition. A physical basis must exist, but if
these hallucinatory cases were viewed from the standpoint of the existence of a
mental conflict in the patient, which was being repressed, and efforts were made
to deal with this in an early stage by psycho-analysis, he believed many of them
would recover.

SCOTTISH DIVISION.

A Special Meeting of the Scottish Division of the Medico-Psychological
Association was held in the Royal College of Physicians, Queen Street, Edinburgh,
on Friday, February 13th, 1920.

Present: Lieut.-Col. Keay, Major Hotchkis, Drs. Buchanan, Drummond, Kerr,
MacDonald, Tuach Mackenzie, Oswald, G. M. Robertson, Skeen, Shaw, Steele,
and R. B. Campbell (Divisional Secretary).

Lieut.-Col. Keay occupied the chair.

Apologies for absence were intimated from Drs. Easterbrook, McRae, Carre,
T. C. Mackenzie, Donald Ross, and Crichlow.

The Secretary read a letter which he had received from the Secretary of the
Scottish Board of Health, requesting the Scottish Division of the Medico-
Psychological Association to submit the names of two " suitable persons ” to the
Board of Health for their consideration in appointing a General Nursing Council
in terms of the Nurses’ Registration (Scotland) Act, 1919. The Secretary stated
that he had referred the matter to the Business Committee, who had nominated
Drs. G. M. Robertson and L. R. Oswald, and that he had sent their names to the
Scottish Board of Health. The Division approved of the Business Committee’s
selection, and also the action taken by the Secretary.

The Nurses’ Registration (Scotland) Act was then considered in detail and
various points discussed. It was decided that the Business Committee should be
authorised to act as an Advisory Committee to the Division’s representatives on
the General Nursing Council, to whom all matters could be referred.

The Division considered it would be expedient to have someone representing
mental nurses nominated as a member of the Nursing Council. In the course of
discussion it was pointed out that the Board of Health had already taken steps to
have this done. It was finally decided that the Secretary should find out if this
was the case, and if on inquiry it was found that no nomination had been made,
Lieut.-Col. Keay and the Divisional Secretary should interview the Board of
Health, and lay stress on the advisability of having someone nominated to
represent the interests of mental nurses.

A vote of thanks to the Chairman for presiding terminated the business of the
meeting.

A Meeting of the Scottish Division of the tyedico-Psychological Association
was held in the Hall of the Royal Faculty of Physicians and Surgeons, Glasgow,
on Friday, March 19th, 1920.

Present: Lieut.-Col. Keay, Drs. Buchanan, Clarkson, Chislett, Easterbrook,
Kate Fraser, Hotchkis, Henderson, Kerr, Macdonald, McRae, Richards, Roberts,
and R. B. Campbell (Divisional Secretary).

Lieut.-Col. Keay occupied the chair.

The Minutes of last divisional meeting were read and approved, and the
Chairman was authorised to sign them.

The Secretary intimated apologies for absence from Drs. G. M. Robertson,
Oswald, Orr, Tuach Mackenzie, Shaw, T. C. Mackenzie, Skeen, Steele, Ross, and
Boyle.

The Secretary read the following letter which he had received from the
Secretary, General Board of Control, regarding the petition which had been sent
to the Board in support of the continued employment of female nurses in the male
wards of asylums-:

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[Copy.]

General Board op Control for Scotland,
Edinburgh ;

March 8 th , 1920.

Sir, —Your letter enclosing a memorial from the medical officers of Scottish
asylums on the question of the attitude of the Asylum Workers’ Union towards the
employment of female nurses in the male wards of asylums was laid before a
meeting of the Board held here on the 3rd inst.

In reply I am directed to state that in the opinion of the Board it is highly
regrettable that an economic dispute, unconnected with the intrinsic merits of the
important question at issue, should imperil a system of nursing which affects the
comfort and happiness of thousands of helpless individuals.

The Board have always regarded the introduction into asylums of the nursing
of male patients by women as among the more important advances in the care of
the insane which has occurred in the history of Scottish lunacy administration.
The Medical Commissioners early recognised its value, and they have constantly
advocated its extension because of its beneficial results and its humanising
influence, not only upon the patients immediately subjected to it, but upon the
general tone of the institutions in which it has been adopted.

For many years in this country the sick of both sexes and of all classes, whether
in hospitals or in private houses, have been tended by female nurses, and the Board
can conceive of no valid reason why the male inmates of asylums, with very few
exceptions, should not equally participate in the same benefit.

The medical officers of Scottish asylums may rest assured that the Board will
continue to use their influence in the direction of supporting and extending the
nursing of the male insane by women.

In view of the importance they attach to the matter, the Board have directed
that a copy of the memorial and of this letter be sent to the Secretary for Scotland
for his information.

I am, Sir,

Dr. Campbell, Your obedient servant,

Stirling District Asylum, A. D. Wood,

Larbert. Secretary.

The Division were gratified to learn of the warm support offered by the General
Board, and unanimously agreed that the letter should be incorporated in the
Minutes. The Secretary was instructed to write the General Board of Control
expressing the thanks of the Division for the letter and for their promise to
support, and at the same time to ask permission to circulate copies of the letter
to the asylum authorities who received the petition, namely, clerks of District
Boards of Control and secretaries of Royal Asylums Boards.

The Secretary submitted a letter which he had received from Dr. John
Macpherson, Senior Commissioner, General Board of Control, proposing that
arrangements might be made during this summer, preferably a date in either the
month of May or June, to visit one of the " boarding-out ” colonies to have a
demonstration of the Scottish system of “ boarding out.” The Division approved
of the proposal, and the Secretary was asked to write Dr. Macpherson thanking
him for his offer. The Secretary was requested to make the necessary arrange¬
ments for the proposed visit.

Drs. T. C. Mackenzie and G. Douglas McRae were unanimously elected
Representative Members of Council for the ensuing year, and Dr. R. B. Campbell
was elected Divisional Secretary.

Dr. D. K. Henderson read an interesting and instructive paper on "Anxiety
States occurring at the Involutional Period,” which was followed by a discussion
in which several members took part.

A vote of thanks to the Chairman for presiding terminated the business of the
meeting.

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IRISH DIVISION.

Special Meeting: Memorandum to the Chief Secretary.

It having come to the knowledge of the Irish Division that the Ministry of
Health 44 Irish Public Health Council,” recently appointed, were at present dealing
with matters possibly vitally affecting the interests of the insane poor and the
future welfare of the Irish Asylum Service, it was decided to hold a special and
urgent meeting of the Irish Division, so that a memorandum embodying the views
of the members be placed, as soon as possible, before the Public Health Council,
who had notified their willingness to receive a deputation from the Irish Division
of the Medico-Psychological Association.

The meeting was held on February 14th, at the Royal College of Physicians,
Kildare Street, Dublin.

Members present: John M. Colles, LL.D., K.C. (in the chair), Lieut.-Col. W. R.
Dawson, Drs. M. J. Nolan, J. O’C. Donelan, Greene, H. Eustace, Irwin, H. R. C.
Rutherford, O’Doherty, John Mills, Rainsford, Gavin, Benson, Leeper (Hon. Sec.).

The Hon. Secretary stated to the meeting that the Parliamentary Sub-Com¬
mittee of the Irish Division were directed at the autumn meeting to prepare a
memorandum in connection with the proposed Public Health Council set up
by the Minstry of Health, and present same to the spring meeting of the Irish
Division. At the time it was not at all clear that this newly-appointed body
intended to deal with the Asylum Service and matters in connection with the
treatment of the insane. It having come to our knowledge that the Public Health
Council was, however, now actively engaged in dealing with these matters, the
Parliamentary Sub-Committee had drawn up a memorandum which they begged
to lay before the members for consideration. It seemed to be of the utmost
importance that the considered views of the members of the Irish Division should
be laid before the Public Health Council before that body attempted to recommend
legislation, especially as the Asylum Service had no representative whatsoever
upon the Health Council, and had apparently been deliberately denied representa¬
tion upon it.

Dr. Nolan had kindly drafted a memorandum which was submitted to the
meeting and discussed clause by clause and finally adopted as amended by the
meeting, and it was decided to accept the invitation of the Public Health Council
and send a deputation to lay the important matters dealt with in the memorandum
before them.

It was proposed by Dr. Mills, Ballinasloe, seconded by Dr. H. Eustace, and
passed unanimously, 44 That the following be asked to form a deputation and wait
on the Public Health Council: Dr. M. J. Nolan, Downpatrick; Dr. J. O’C.
Donelan, Richmond Asylum; Dr. Greene, Carlow; Dr. Martin, Letterkenny;
Dr. O’Doherty, A.M.O., Omagh District Asylum; Dr. Rainsford, Stewart Asylum;
Dr. Gavin, Mullingar Asylum; Dr. Leeper to act as Hon. Secretary.”

Dr. O’Doherty wished a clause inserted dealing with the compulsory retire¬
ment of medical superintendents at an age limit. This was fully discussed, but
not generally approved by the meeting.

Memorandum of the Irish Division of the Medico-Psychological
Association of Great Britain and Ireland relative to Lunacy
Administration in Ireland and other matters affecting the Improve¬
ment and Increased Efficiency of the Irish Asylum Service.

In connection with the proposed establishment of a Ministry of Health for
Ireland, the Irish Division of the Medico-Psychological Association directs
attention to the special needs of the Asylum Service in Ireland.

The care and treatment of the insane, as a branch of Public Health service,
cannot properly fail within the ordinary scope of local government administration.
The proportion of the population of Ireland concerned in this service is very
large, the personnel of the staff employed very numerous, and the service itself
is highly technical and specialised. This Division is convinced that the interests
of the insane must suffer unless the Board of Health is in direct touch, through
competent representation, with the governing bodies and medical officers of the
Asylums.

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183

It is submitted that this specialised service should be under the immediate
control of a strong Lunacy Commission in analogy to the Board of Control in
England—the Commissioners being associated with the Board of Health in
whatever manner seems best calculated to ensure the general unity of control
aimed at. The Lunacy Commissioners should be invested with adequate
authority, and it would be possible (subject to the approval of the Lord Chancellor
of Ireland) to place the Commissioners in such relation with the office of the
Registrar in Lunacy that the position of the Commissioners would be fortified
by the Lord Chancellor's judicial powers, and that the functions of the Board
of Health, the Lunacy Commissioners and the Lord Chancellor’s officers would
be so co-ordinated that there should be no overlapping.

For very many years the law with regard to the insane in Ireland has remained
practically unchanged, and it is only by good will on the part of all concerned that
tolerable conditions are made possible in practice, not as the result of law, but in
spite of it. It is eminently desirable that the law should be codified and brought
up to date, but pending such codification legislation is urgently and particularly
needed to deal with the following matters:

(1) Affecting the patients more directly.

(2) Bearing on the institutions for the insane.

(3) Points primarily affecting the asylum officials.

(4) Auxiliary asylums and 11 boarding out.”

(1) Affecting the Patients more directly.

Admission — Discharge — Transfer — Deportation —“ Voluntary Boarders .”

Admission. —It has been pointed out that the insane poor should not be treated as
criminals to qualify them for the treatment of their mental disease. The use of the
Dangerous Lunatic Form should be abolished, and patients admitted to asylums on
an amended Form 0 D ” or on an urgency form which shall be mandatory. In any
event the word 44 destitute” in this Form 44 D ” should be deleted, as it gives rise
to many false declarations, and often operates against the interests of the rate¬
payers. The certification should be uniform. It is anomalous that while one
certificate suffices for a pauper, a 44 paying patient ” requires two medical certificates.

Mental Deficiency Act. —That an act on the lines of the Mental Deficiency Act,
1913, be extended to Ireland.

Voluntary hoarders. —There seems to be no valid reason why similar facilities
for the admission of voluntary boarders to private, county, and district asylums
should not be extended to Ireland by legislation on the same lines that operated in
England and Scotland.

An alternative legal designation, such as "county” or 44 borough > mental
hospital,” might be arranged as in England.

Discharge .—Legislation should enable the resident medical superintendent to
discharge patients for a prolonged period 44 on probation,” and provide that such
patients or their custodians should receive the grant-in-aid until such time as their
names would be removed from the asylum register as 44 discharged.”

Transfer .—Subject to an agreement between the committees of management of
the asylums concerned, with the concurrence of the next-of-kin (if any), the Commis¬
sioners should have the power on the recommendation of the resident medical
superintendent to transfer patients from one asylum to another for such a period
as may be arranged, and renewed, if necessary, from time to time.

Deportation. —An Act should be introduced to extend to Ireland the provisions
of the Act of Settlement in the matter of Deportation of Lunatics.

(2) Points bearing on the Institutions.

Establishment of Out-clinics—Paying Patients' Department—Affiliation
with a Central Laboratory for Research—Affiliation with Special 44 Out-clinics ”
( Tuberculosis , Dental and Venereal)—Compulsory Acquisition of Lands for
Asylum Farms—Reform as to the Granting and Removal of Licenses to Private
Asylums—Need of Increased 44 Grant-in-Aid."

Out-clinics. —In connection with each asylum, consulting rooms should be
provided (arrangements might be made for the use of the existing dispensaries)

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where voluntary patients would get free advice from one of the asylum medical
officers at certain stated times.

Paying patients' department in district asylums. —The committee of manage¬
ment should be empowered to have in each asylum a ward or division restricted
for the use of patients paying full cost of maintenance, in which such patients would
receive special dietary and clothing when not under treatment in the hospital
division. Such a step would be the means of securing larger contributions for
many patients than at present, when no differentiation is made between the paying,
partially paying and non-paying patients.

The establishment of central laboratory for pathological research in mental and
nervous disease. —Pathological research in insanity is lamentably lacking, and the
optional clause in the Lunacy (Ireland) Act, 1901, relative to the support of such
a laboratory should be made mandatory on county councils and a contribution
levied from them, which, in addition to State grant from sums provided for patho¬
logical research, would suffice to set up a central laboratory in which the assistant
medical officers of asylums should be required to attend during part of their study
leave to study under the director’s guidance.

Special out-clinics. —If tubercular, dental and venereal out-clinics are set up by
the Public Health Acts, these clinics should be made available for the treatment
of such patients in district asylums as, in the opinion of the resident medical
superintendent, would be suitable cases for investigation and treatment.

Compulsory acquisition of lands for asylum purposes .—As asylum farms supply
the institutions with food, etc., at first cost of production, and are a very great help
to economical management and of importance to the well-being and improvement
of the patients, it would be desirable that committees of management, subject to
the concurrence of the Commissioners, should be empowered to acquire such lands
as they may require approximate to or within easy distance of the institutions,
under somewhat the same terms as lands can be taken for the purposes of the
Labourers (Irel.) Acts. At present committees shrink from competition with the
public.

Licence reform in case of private asylums. —The existing procedure has been com¬
pared as similar to that of the granting of ordinary publicans’ licences, and licences
should only be granted or renewed by the Lord Chancellor on the recommendation
of the Lunacy Commissioners. Such licences should not be given unless the
applicant undertakes to arrange for the insane no less medical care than is
expected for the insane poor. No establishment for the insane should be with¬
out at least one resident medical practitioner.

Need of a subsidiary “grant-in-aid ” from the Consolidated Fund .—The
transfer of the 4s. “ grant-in-aid ” from the Consolidated Fund (under the pro¬
visions of the Local Government (Ireland) Act, 1898) eventuated in a considerable
loss to the Irish district asylums, as has been repeatedly pointed out by the com*
mittees, who feel that they have a very real grievance under that head. As the
“ grant-in-aid” was originally given as a moiety of relief to the cost of maintenance,
which of late years has nearly trebled, it would be but quite equitable to increase
the grant proportionately to the existing high cost. A subsidiary grant from a
non-fluctuating source should be given to make up such deficiency of the 4s. grant
as may arise each year, and at the same time extra grant should be given in relief
of the local rates. It is certain that for many years the cost of maintenance will
be far in excess of any pre-war cost, and it would not be too much to ask the State
to give a grant of 10s. per head weekly, particularly as there are so many senile
cases in lunatic asylums, who would be entitled to that extent of State relief under
the Old Age Pension Act had they not become insane. It must be remembered
also that practically all the patients in district asylums would, if not insane, be the
recipients of State relief under other Acts, such as State Insurance, etc.

(3) Points Primarily Affecting Asylum Officials.

Qualification of Medical Officers—Special Study by Assistant Medical
Officers—Training of the Attendant Staff—Amended Terms of Superannua¬
tion.

The medical qualifications of medical officers.—' The enactments of the Local
Government Act of Ireland, 1898, with reference to the qualifications and mode of

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•election of asylum medical officers (61 and 62 Vic., Cap. 37), should be retained.
In the case of assistant medical officers they should be amplified. Newly appointed
assistant medical officers should be compelled to take out some recognised special
qualification in mental disease. In the interests of the insane the functions of the
resident medical superintendents as the chief executive officials should be accurately
defined and safeguarded. In the event of legislative changes provision should
be introduced for safeguarding the asylum officials.

Study leave and salaries of assistant medical officers. —The assistant medical
officers, all of whom in a limited service cannot hope to attain senior rank, should
be placed on such terms as would enable them to keep up with general medical
progress, and, if they so desire, to retire after a certain term of years, receiving
a compounded gratuity estimated on their pensionable service. Meantime their
salaries should be such as to enable them to marry, and they should be provided
with suitable residence or rent in lieu thereof. The assistant medical officer,
or, if more than one, the senior, should be entitled " deputy resident medical
superintendent.”

In connection with the foregoing suggestions the question of converting the
asylum service into a national service might well receive consideration. Weighty
arguments have been brought forward in support of this in the cases of the Poor
Law service, and on grounds of efficiency might be argued with greater force
.regarding the asylum service.

Training of attendant staff. —Too much importance cannot be placed on
methods to secure efficient attendant staffs, consequently the Commissioners
-should lay down such rules as to training and examination as would be calculated
to secure men and women well fitted for their responsible task. It should be
obligatory on committees to see that such rules are carried into effect. The
staffs should be divided into two classes—"probationary” and "qualified or
trained.” Permanent appointments should be made only from the latter class,
with due regard to age, health and general character.

Need of amendments to Asylum Officers' Superannuation Act .—In view of the
fact that the terms of the Asylum Officers’ Superannuation Act, 1909, were framed
when the value of money was very considerably higher than the current rates,
the Act requires amendment which was sought for even before the war, vie. the
term of ten years’ service, that on which the calculation for pension has to be made
under the terms of the Act, should be reduced to five at most. Superannuation
on the present terms would in some grades be altogether inadequate to meet the
cost of subsistence.

(4) "Auxiliary Asylums” and "Boarding Out.”

Auxiliary asylums. —In the event of any other system for dealing with the
so-called " harmless insane ” being considered necessary, as, for example, in
"auxiliary asylums” as proposed in the Local Government (Ireland) Act, the
Irish Division of the Medico-Psychological Association is of opinion that any
measure of success likely to be met with would be in the direction of creating
such auxiliaries as special "departments” of the existing "district asylums.
The combination of the establishment charges, the facilities for the more
specialised treatment of the insane and the utilisation of an experienced resident
medical staff would secure the most efficient and economical results. In many
places the necessary accommodation would be secured by the adaptation of build¬
ings in the neighbourhood of the asylum; many country mansions are now in the
market.

" Boarding out." —The legislation necessary to permit of a trial of "family care ”
-should certainly be enacted. Though there is much against its general success
at the moment, yet at a time when domestic service is an acute problem, many
patients might be located in suitable surroundings with advantage to themselves
and their custodians. This applies more particularly to the agricultural class,
which comprises the vast majority of district asylum patients. The wave of moral
^degradation which at present sweeps industrial centres renders the application
of the scheme unsuited to them for the time being.

In conclusion the Irish Division of the Medico-Psychological Association desire

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[April.

to reiterate in the strongest terms their conviction that a strong Lunacy Com¬
mission is essential to the efficient administration of everything connected with
the care and treatment of the insane. They urge the constitution of such a
Commission, and the enactment of legislation on the matters dealt with in this
memorandum, giving the necessary legal machinery to initiate the many urgent
reforms so long needed for the betterment of the insane and the general well-being
of the community at large.

MENTAL DISORDERS: STUDY AND TREATMENT IN EARLY

STAGES.

Psychiatric Clinics.

To the Editor of the Times .

Sir, —Permit us through the medium of your columns to draw attention to the
urgent need of reform in the methods of dealing with disorders of the mind in
this country. The insane are still dealt with under the provisions of the Lunacy
Act, 1890. In 1914 the Medico-Psychological Association of Great Britain and
Ireland, after careful inquiry into the status of British Psychiatry, urged reforms in
the methods of treatment of incipient mental disease, and the provision of facilities
for study and research. In November, 1918, this Association adopted a report of
a sub-committee appointed to consider the amendment of the existing lunacy laws.
This report states that there are very few facilities for patients who are threatened
with mental breakdown to obtain skilled treatment until they are placed under
certificates under the Act, whereas the early symptoms of disorder often occur
long before certification is possible; that, owing to treatment being delayed, the
most valuable time for adopting measures to secure early recovery is lost; that
the public, which is alive to the material and moral damage which certification
often inflicts on the patient and his relatives, refuse to resort to it, even when it has
become possible, and thus still further postpone the adoption of efficient treatment;
that where certification has to be resorted to, the subsequent course of events often
shows that this might have been avoided had there been facilities for treatment
under other conditions; that many medical practitioners, having had no oppor¬
tunity of gaining knowledge of the manifestations and treatment of mental disorders
in their early stages, fail to recognise the seriousness of the condition, and are,
further, deterred by the necessity of certifying the patient from advising suitable
treatment.

The existing Lunacy Act, protecting, as it does, society, and safeguarding the
liberty of the subject, allows insufficient scope for the treatment and cure of the
patient.

The position—and we cannot believe that the public can be aware of it—is that
a very large class of the community is debarred from obtaining advice and treat¬
ment (except such as can be given in an out-patient department, and even this
provision is extremely rare), in the early stages of disease, and this owing to the
operation of laws designed mainly with a view to protecting the interests of that
class.

The proposals made by the experts composing this sub-committee to remedy
the defects summarised correctly represent the view of all with practical know¬
ledge of the subject. These aim at the provision of treatment in the early and
curable stages of mental disorder without certification, which provision would be
rendered possible by a short amending Bill to the Lunacy Act, embodying the
reforms most urgently needed. The proposals are, in brief, as follows : The pro¬
vision of clinics—the so-called psychiatric clinics—in large centres of population,
and especially in connection with the general hospitals, and where schools of
medicine exist; the extension of the system of voluntary admission (which now
obtains in respect of licensed houses and registered hospitals for the insane), so
that patients, whether of the private or rate-aided class, may place themselves for
treatment in county borough mental hospitals; or further provision for the private
patient class, so that, with the approval of the Board of Control, such may be

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received without certification (but with the cognisance of the central authority)
into homes, privately owned or supported wholly or partly by voluntary contribu¬
tions, and also into existing public and private mental hospitals (“ licensed
houses ”) ; also received, with the sanction of the board, as single patients, without
certification, provided that a medical practitioner gives a written recommendation,
stating that suitable treatment can be obtained in the proposed house.

Of the above proposals, that concerned with the establishment of clinics in
psychiatry—with in- and out-patient departments—as an integral part of the
general hospital system, is the most important. Our main hope of avoiding the
never-ending extensions to existing asylums lies in the operation of these clinics.
In this respect this country is deplorably backward as compared with other
European countries, great and small, with the United States, and with some of
the component parts of the British Empire. This is the more regrettable since it
is in these clinics that students and the future holders of posts in mental hospitals
should be taught and all available means of research be provided. For none of
these purposes is the present "asylum ” system adequate. In such clinics patients
would be received without reception orders or certificates, and would be subjected
to the minimum of official supervision; and on these lines they might be treated
for a stated period—not less than six months. The late Dr. Henry Maudsley was
the first to give practical expression to the urgent need for these clinics when,
eleven years ago, he made his munificent gift—ultimately amounting to £ 40,000—
to the London County Council, which rendered possible the erection of the
Maudsley Neurological Hospital, Denmark Hill. This hospital has rendered
most valuable service during the war in the treatment of patients and the instruc¬
tion of medical officers. It is gratifying to think that Dr. Maudsley’s wish, that
his hospital should be used for the treatment of early cases of mental disorders,
without certification, and for the teaching of psychiatry, is likely ere long to be
realised.

In this connection it will be of interest to recall that in the case of mentally-
disordered soldiers the Army authorities arranged, during the war, that they be
received into military mental hospitals without any orders or certificates. These
men were, in the first instance, not sent to their asylums until the mental disability
had lasted for a period of nine months and was deemed incurable; later it was
decided that this step should be taken after observation and treatment for such an
extended period as was necessary to form the opinion that recovery was unlikely.
Large numbers of the men were received in very early phases of the disease. The
immense boon and solace this wise step conferred upon the patients and their
relatives are best known to those physicians who have been connected with these
hospitals. If these men could be treated thus whilst in khaki, they could, and
should, be similarly treated as civilians, and under far better medical conditions
than in asylums. The war has in this, as in other instances, been a means of
education.

The necessity of carrying out the reforms above outlined has been repeatedly
urged in the leading organs of the medical profession. That the Board of Control,
the central authority in matters appertaining to the insane, is well aware of the
pressing need for them is sufficiently shown by the recommendations contained in
its fourth and fifth annual reports for the years 1917 and 1918. From the latter
it appears that the Board has submitted to the Lord Chancellor and the Secretary
of State the heads of a Bill, with a recommendation that it should be introduced
into Parliament at the earliest practicable date, and be pressed forward as a
measure of urgent importance to the health and welfare of the people. In October,
1918, a deputation representing the National Council of Mental Hospital Autho¬
rities was received at the Home Office, and it was abundantly clear that that
Department was in sympathy with the representations made with a view to these
reforms. Up to the present time, however, we have no evidence that any step
whatever has been taken to the desired end.

We believe it to be the fact that in the present Parliament there are a number
of medical men and others interested in this matter, and there is a reasonable
hope that such a Bill would meet with sympathy and a swift passage into law.

We would, therefore, earnestly appeal to you to lend your powerful support in
this matter, so that the introduction by the Government of the legislation neces-
aary to facilitate, on the lines indicated, the early treatment of mental and allied

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nervous disorders may be no longer delayed, and a grievous injustice to a very
large class of suffering humanity may be removed.

We are, Sir,

Your obedient servants,

Pontypridd.

Thomas Barlow.

Clifford Allbutt.

G. H. Savage.

Frederick W. Mott.
Robert Armstrong-Jonbs.
John Lynn-Thomas.

W. McDougall.

Charles S. Myers.

G. Elliot Smith.

R. Percy Smith.

Bedford Pierce.

Robert B. Wild.

David Drummond.

A. H. Trow.

M. Thomas.

Times , February 6th, 1920. E. Goodall.

MENTAL DISORDERS.

To the Editor of the Times .

University of Edinburgh.

Sir, —As one living under different and happier laws than the writers of the
letter on the above subject, I desire to point out that in Scotland mentally deranged
patients who have means, or whose friends can pay for their support, are able at
the present time to receive curative treatment in any house or home without being
certified to be insane and without being sent to any asylum. Insane patients are
accordingly often sent by physicians from England to Scotland to benefit in this
way by the kindly provisions of its considerate system of laws, and to avoid the
stigma of certification as a lunatic or detention in an English asylum while under¬
going curative treatment. These powers have existed in Scotland for half a
century, and after such a prolonged and completely successful experiment there
should be no hesitation in conferring similar privileges on the people of England,
and in removing not only an invidious but what is to many sensitive persons and
families a most cruel anomaly.

I have, in the second place, to point out to reformers of the lunacy laws that
something more requires to be done than the mere repeal of laws that obstruct
reform and the enactment of others that confer new powers ; there is also the
question of financial aid. In Scotland we possess practically all the powers the
signatories desire, but the voluntary treatment of the poor—that is, the State-aided
or parochial class—is for practical purposes a dead letter for this peculiar reason:
that a grant in aid is given by the State for the maintenance of any person who is
certified to be a lunatic, but this grant is withheld, although the patient be treated
on similar medical lines, if he or she be not certified insane. Human nature being
what it is, this is a cause of delay in obtaining treatment, and it encourages the
certification of the patient as a lunatic for the sake of the Government grant,
rather than treatment without certification.

The objects desired by the signatories have the sympathy of everyone engaged
in the care of the mentally afflicted. Our legislators may grant the powers asked
for with an easy mind, as they have existed in Scotland for over 50 years and they
have not been abused. Lastly, the financial problems connected with these
admirable ideals must be carefully worked out, otherwise the powers, if granted,
may be found worthless in practice.

I am,

Yours sincerely,

George M. Robertson,

Times , February 12th, 1920. Professor of Psychiatry.

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THE REPROACH OF PSYCHIATRY IN ENGLAND.

Of all the branches of medicine psychiatry seems still to suffer from that relative
neglect and to labour under those disadvantages which tradition assigns to the lot
of the youngest sister. From time to time the calm of apparent stagnation is
ruffled by some breeze of public agitation seeking to direct attention to defects,
administrative or otherwise, yet such superficial disturbance bears little proportion
to the immense undercurrent of dissatisfaction running strongly, within the pro¬
fession itself, in the minds of all who have the interests of psychiatry in England
at heart. If we inquire the reasons of this they are found to reside in a combina¬
tion of factors on which stress has been laid repeatedly, with as yet little obvious
result. It is imperative that the fons et origo of the dissatisfaction, which percolates
through all the strata of asylum life, should be clearly laid bare, else the stream
will continue to run muddily. It will, we believe, be granted that the scientific
health of the asylum unit—that is, of the medical staff—takes its tone from the
superintendent; should he be keen on the advancement of psychiatric learning,
his subordinates find themselves in a stimulating atmosphere, the influence of
which is reflected in the actual treatment of the inmates, as well as in the con¬
tributions from the staff to the body of psychiatric doctrine. On the other hand,
if the senior has been selected more for social than for scientific equipment, or
should he allow himself to be more concerned with the asylum laundry or meat-
supply than with the healing of the mind, not only is the general scientific level of
the institution lowered, but any junior medical officer is only too apt to find his
youthful enthusiasm starved in an uncongenial environment; he sinks to the
humdrum level of those with whom he is inevitably in such close association.
The asylum officer who can rise superior to depressing surroundings is the excep¬
tion. We should be the last to belittle the importance of social and administrative
gifts in the smooth running of the asylum communities of the country, which from
their very nature must be self-contained and self-sufficient, but psychiatry exists as
a branch of medicine for the prevention and cure of mental disease, and nothing
can ever be permitted to usurp this function. No elaborate schemes of internal
decoration, no ingenuity of kitchen appliances, no perfectly fitted miniature
theatres or admirably supplied gardens, farms and piggeries, can make up for
indifference to clinical and pathological reports, neglect of modern technique in
treatment, or absence of stimulus to increase the annual percentage of cures or
relief.

The promotion or advancement of a medical officer, further, sometimes seems
to depend so little on his professional knowledge that he has scant inducement to
devote himself to an earnest study of the subject. His work is too often seen to
begin and end with the discharge of routine—essential duties which fatigue without
stimulating—and with the accomplishment of which any incentive to personal
research vanishes. When he has time to think over things he fully realises the
tremendous material at his disposal, the fascination of the study of the complex
case, the therapeutic problems with which he is surrounded, yet evening finds him
unable or disinclined to sit down to serious work. There is, however, another
reason for the paucity of scientific output. Friendly conversation with the average
asylum medical officer has often elicited the confession that he does not know how
or where to begin his task; he is conscious of not being abreast of knowledge in
many instances, and is sorely in lack of a guiding and advising mind. If this
position be analysed it will be seen to derive from the fact that so few centres for
the organised teaching of psychiatry exist, and the equipment of some leaves much
to be desired. Of how many of our asylum officers can it be said that they
have attended courses of theoretic and practical psychiatry at home or abroad P
When do they get a four or six weeks' leave of absence to follow post-graduate
instruction in their life’s work at a recognised centre P Nay, how many of them
have ever spent an unforgettable Wanderjahr in foreign school or laboratory prior
to their entering on their professional career of psychiatric expert ? Not that
foreign experience of itself confers a cachet unobtainable at home, for our home
material, in no way inferior, is calling out for investigation and research ; but as
long as our young medical officers drift untrained into asylum work, so long will
the reproach continue that in this country psychiatry is not adequately studied.

On other occasions we have spoken of the peculiar restrictions and handicaps of

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certain phases of asylum life for the junior staff ; we are more concerned for the
present to appeal emphatically for better chances for training, better facilities to
keep abreast of scientific advance, greater endeavour to make the first step on the
ladder encouraging, more serious efforts to utilise precious time and valuable stuff.
Is it too much to hope that the authorities who control asylum affairs should one
day claim a certain standard of professional attainment on the part of medical
officers entering the service, and insist similarly on granting members of asylum
staffs post-graduate leave ? We are confident that the outlook is bright in reality,
and that the stirring among what only the cynic would call the dry bones augurs
well for the future. We can imagine a central authority fully conversant with the
best methods employed in the whole range of the practice of psychiatry, and able
to give local bodies information and guidance as to management, equipment, and
expectation of output on the scientific side no less than on the others ; we can
foresee the day when prophylaxis and prevention will be elevated to their true
importance by the establishment of clinics and observation wards staffed by trained
men with all-round experience. The problem confronting us is the elaboration of
the best way to organise and utilise the sources of psychiatric energy which, we are
convinced, are only waiting to be tapped.— Lancet , March 6th, 1920.

NURSES REGISTRATION ACT, 1919. ENGLAND AND WALES.(*)

9 & 10 Geo. 5, Ch. 94. 23rd December 1919.

1. —(1) For the purposes of this Act, there shall be established a General
Nursing Council for England and Wales (in this Act referred to as “ the Council ”),
which shall be a body corporate by that name with perpetual succession and a
common seal with power to acquire and hold land without licence in mortmain.

(2) The Council shall be constituted in accordance with the provisions con¬
tained in the Schedule to this Act.

(3) The seal of the Council shall be authenticated n the prescribed manner
and any document purporting to be sealed with the said seal so authenticated
shall be receivable in evidence of the particulars stated in that document.

2. —(1) It shall be the duty of the Council to form and keep a register of nurses
for the sick in this Act referred to as “ the register ”) subject to and in accordance
with the provisions of this Act.

(2) The register shall consist of the following parts:—(a) a general part
containing the names of all nurses who satisfy the conditions of admission to
that part of the register: (6) a supplementary part containing the names of male
nurses: (c) a supplementary part containing the names of nurses trained in the
nursing and care of persons suffering from mental diseases: (d) a supplementary
part containing the names of nurses trained in the nursing of sick children:
(#) any other prescribed part.

Where any person satisfies the conditions of admission to any supplementary
or prescribed part of the register, his name may be included in that part of the
register notwithstanding that it is also included in the general part.

(3) A certificate under the seal of the Council duly authenticated in the
prescribed manner stating that any person is, or was at any date, or is not, or
was not at any date, duly registered under this Act shall be conclusive evidence in
all courts of law of the fact stated in the certificate.

(4) Any reference in this Act to the register shall, unless the context otherwise
requires, be deemed to include a reference to any part of the register, and the
expression u registered” shall be construed accordingly.

3. —(1) The Council shall make rules for the following purposes:—(a) for
regulating the formation, maintenance and publication of the register; ( b ) for
regulating the conditions of admission to the register; (c) for regulating the
conduct of any examinations which may be prescribed as a condition of admission
to the register, and any matters ancillary to or connected with any such examina¬
tions ; (d) for prescribing the causes for which, the conditions under which, and
the manner in which nurses may be removed from the register, the procedure
for the restoration to the register of nurses who have been removed therefrom,
and the fee to be payable on such restoration; (*) for regulating the summoning

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191

of meetings of the Council and the proceedings (including quorum) of the
Council; (/) for enabling the council to constitute committees and for authorising
the delegation to committees of any of the powers of the Council, and for
regulating the proceedings (including quorum) of committees; ( g) generally for
making provision with respect to any matters with respect to which the Council
think that provision should be made for the purpose of carrying this Act into
effect (including provision with respect to the issue of certificates to nurses
registered under this Act and with respect to the uniform or badge which may
be worn by nurses so registered), and for prescribing anything which under this
Act is to be prescribed.

(2) Rules under this section shall contain provisions—(a) requiring as a con¬
dition of the admission of any person to the register that that person shall have
undergone the prescribed training, and shall possess the prescribed experience, in
the nursing of the sick; and ($) requiring that the prescribed training shall be
carried out either in an institution approved by the Council in that behalf or in the
service of the Admiralty, the Army Council, or the Air Council; and (c) enabling
persons who, within a period of two years after the date on which the rules to be
made under the provisions of this paragraph first come into operation, make an
application in that behalf (in this Act referred to as " an existing nurse's applica¬
tion "), to be admitted to the register on producing evidence to the satisfaction of
the Council that they are of good character, are of the prescribed age, are persons
who were for at least three years before the first day of November, nineteen
hundred and nineteen, bond fide engaged in practice as nurses in attendance on
the sick under conditions which appear to the Council to be satisfactory for the
purposes of this provision and have adequate knowledge and experience of the
nursing of the sick.

(3) Rules made under this section shall not come into operation unless and
until they are approved by the Minister of Health.

(4) Every rule made under this section shall be laid before each House of
Parliament forthwith, and, if an Address is presented to His Majesty by either
House of Parliament within the next subsequent twenty-one days on which that
House has sat next day after any such rule is laid before it praying that the
rule may be annulled or modified, His Majesty in Council may annul or modify
the rule, and, if annulled, it shall thenceforth be void, and, if modified, it shall
thenceforth have effect as so modified, but without prejudice to the validity of
anything previously done thereunder.

4. —(1) The Council may, with the previous sanction of the Minister of Health,
appoint a person to act as registrar of the Council, and may, subject to the consent
of the Minister as to numbers, employ such other officers as the Council consider
necessary.

(2) There shall be paid to*the registrar and the officers of the Council such
salaries or remuneration as the Council with the approval of the Minister of
Health may from time to time determine.

( 3 ) Any expenses incurred by the Council in carrying this Act into effect,
including expenses in connection with examinations or prosecutions under this
Act and, subject as hereinafter provided, the travelling expenses of and sums paid
on account of subsistence allowance to members of the Council, shall be defrayed
out of the sums received by the Council by way of fees under this Act:

Provided that the amount to be allowed to members of the Council in respect of
travelling expenses and subsistence allowance shall be calculated in accordance
with directions to be given by the Minister of Health.

(4) The accounts of the Council shall be audited in such manner, and by such
person, as the Minister of Health may from time to time direct, and copies of the
accounts, and of any report made on the accounts, shall be transmitted by the
Council to such persons as the Minister may direct.

5. —(1) There shall be paid to the Council in respect of every application to be
examined or to be registered under this Act, and in respect of the retention in any
year of the name of any person on the register, such fees respectively as the Council
may, with the approval of the Minister of Health, from time to time determine:

Provided that—(a) in the case of an existing nurse’s application the amount of
the fee payable on the application shall be such sum, not exceeding one guinea, as
the Council, with such approval as aforesaid, may determine; ana ( b ) the amount

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[April,

of the fee payable in respect of the retention in any year of the name of any person
on the register shall not exceed two shillings and sixpence.

(2) The Council may charge for any certificate or other document issued, or in
respect of any services performed, by them, such fees as may be prescribed.

6. —(1) Any person who proves to the satisfaction of the Council that he has
been registered either generally as a nurse for the sick or as a nurse of some
special class in any part of His Majesty’s dominions outside the United Kingdom,
being a part of those dominions to which this section applies, shall be entitled, on
making an application in the prescribed manner and paying such fee, not being
greater than the fee payable on ordinary applications for registration under this
Act, as the Council may demand, to be registered in a corresponding manner
under this Act.

(2) This section applies to any part of His Majesty’s dominions as respects
which the Council are satisfied— (a) that there is in force therein an enactment,
or a provision of any kind having the force of law, providing for the registration
of nurses under some public authority; (b) that persons registered under this Act
are admitted to the register established under the said enactment or provision on
terms not less favourable than those contained in subsection (1) of this section
and (c) that the standard of training and examination required for admission to
the register of nurses established under the said enactment or provision is not
lower than the standard of training and examination required under the Act.

(3) In the event of provision being hereafter made for the establish me ntof a
register of nurses in Scotland or Ireland, the Council shall make rules under this
Act enabling persons registered as nurses in Scotland or Ireland, as the case may
be, to obtain admission to the register of nurses established under this Act; and,
with a view to securing a uniform standard of qualification in all parts of the
United Kingdom, the Council shall, before making any rules under this Act with
respect to the conditions of admission to the register, consult with any Nursing
Councils which may be established by Parliament for Scotland and Ireland
respectively.

7. —(1) Any person aggrieved by the removal of his name from the register may,
within three months after the date on which notice is given to him by the Council
that his name has been so removed, appeal against the removal in manner pro¬
vided by rules of court to the High Court, and on any such appeal the High Court
may give such directions in the matter as it thinks proper, including directions as
to the costs of the appeal, and the order of the High Court shall be final and
conclusive and not subject to an appeal to any other court.

(2) Any person aggrieved by the refusal of the Council to approve any insti¬
tution for the purpose of the rules under this Act relating to training may appeal
against the refusal to the Minister of Health, and the Minister, after considering
the matter, shall give such directions therein as he thinks proper, and the Council
shall comply with any directions so given.

8. —(1) Any person who— (a) not being a person duly registered under this Act,
at any time after the expiration of three months from the date on which the
Minister of Health gives public notice that a register of nurses has been compiled
under this Act, takes or uses the name or title of registered nurse, either alone or
in combination with any other words or letters, or any name, title, addition,
description, uniform, or badge, implying that he is registered under this Act or is
recognised by law as a registered nurse; or (b) being a person whose name is
included in any part of the register, at any time after the expiration of the period
aforesaid takes or uses any name, title, addition, description, uniform or badge, or
otherwise does any act of any kind, implying that his name is included in some
other part of the register ; or (c) at any time with intent to deceive makes use of
any certificate of registration as a nurse issued under this Act to him or any other
person, shall be liable on summary conviction to a fine not exceeding, in the case
of a first offence, ten pounds, and in the case of a second or any subsequent offence
fifty pounds.

(2) If any person wilfully makes, or causes to be made, any falsification in any
matter relating to the register, he shall be guilty of a misdemeanour and shall, on
conviction thereof, be liable to a fine not exceeding one hundred pounds.

9. —(1) This Act shall not extend to Scotland or Ireland.

(2) This Act maybe cited as the Nurses Registration Act, 1919.

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Schedule.

Constitution of Council .

1. The Council shall consist of twenty-five members.

2. On its first constitution the Council shall be composed of the following
persons, namely:

Two persons, who shall not be registered medical practitioners, or nurses, or
persons concerned with the regular direction or provision of the services
of nurses, appointed by the Privy Council:

Two persons appointed by the Board of Education:

Five persons appointed by the Minister of Health, after consultation with
persons and bodies having special knowledge and experience of training
schools for nurses, of the work of matrons of hospitals, of general and
special nursing services, and of general and special medical practice:

Sixteen persons, who are or have at some time been nurses actually engaged
in rendering services in direct connection with the nursing of the sick,
appointed by the Minister of Health after consultation with the Central
Committee for the State Registration of Nurses, the College of Nursing,
the Royal British Nurses’ Association, and such other associations or
organised bodies of nurses or matrons as represent to the Minister that
they desire to be consulted in the matter.

The Minister, in making appointments under this provision, shall have
regard to the desirability of including in the Council persons having
experience in the various forms of nursing.

3. The first members of the Council shall hold office for such term, not less than
two years and not exceeding three years from the commencement of this Act, as
the Minister of Health may determine.

4. After the expiration of the term of office of the first members of the Council,
the Council shall be composed of nine persons appointed respectively by the Privy
Council, the Board of Education, and the Minister of Health as aforesaid, and of
sixteen persons, being persons registered as nurses under this Act, elected in
accordance with the prescribed scheme and in the prescribed manner by the persons
so registered at the date of election.

5. Any members of the Council other than the first members thereof shall hold
office for a term of five years.

6. If the place of a member of the Council becomes vacant before the expiration
of his term of office whether by death, resignation, or otherwise, the vacancy shall
be filled by appointment by the body or persons by whom the member was appointed,
or if the vacating member was an elected member by the Council.

The Council in co-opting a member under the foregoing provision shall, so far
as practicable, select a person, being a person registered as a nurse under this Act,
who is representative of the same interests as those represented by the vacating
member.

Any person appointed or elected to fill a casual vacancy shall hold office only so
long as the member in whose stead he is appointed or elected would have held office.

7. Any member ceasing to be a member of the Council shall be eligible for
re-appointment or re-election.

8. The powers of the Council may be exercised notwithstanding any vacancy in
their number.

( l ) The Nurses Registration (Scotland) Act, 1919, will be printed in the July
number.

LONDON COUNTY COUNCIL.

Lectures and Practical Courses of Instruction at the Maudsley
Hospital, Denmark Hill, S.E. 5, for a Diploma of Psychological
Medicine, 1920.

Part /.

1. Twelve Lectures on the Anatomy of the Nervous System. By Sir Frederick
Mott, K.B.E., M.D., LL.D., F.R.S., F.R.C.P.

Practical Instruction and Demonstrations. (8 Sessions of two hours each.)

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2. Twelve Lectures on the Physiology of the Nervous System. By F. Golla,
M.D., F.R.C.P., Physician, St. George’s Hospital.

Practical Physiology, (xo Sessions.) By F. Golla, M.D., F.R.C.P. (The
Object of this Course is to put students in possession of such methods as might
be employed in minor research work in mental diseases.)

3. Ten Lectures on Psychology. By J. V. Lowson, M.A., M.D.Edin.,
Demonstrator of Psychology, University of Cambridge.

Practical Psychology. Practical Work and Demonstrations. (8 Sessions.)
By J. V. Lowson, M.A., M.D.Edin.

Part II.

1. Twelve Lectures on the Diagnosis, Prognosis and Treatment of Mental
Diseases. By C. Hubert Bond, D.Sc., M.D., F.R.C.P.

2. Two Lectures on Crime and Responsibility. By Sir H. Bryan Donkin,
M.D., F.R.C.P.

3. Two Lectures with Demonstrations of Cases on the Practical Aspect of
Mental Deficiency. By F. C. Shrubsall, M.D., F.R.C.P. (Principal Assistant
Medical Officer, Public Health Department, L.C.C.)

4. Six Lectures on the Pathology of Mental Diseases including Brain Syphilis,
its Symptomatology and Treatment, with Demonstrations. By Sir F. W. Mott,
K.B.E., M.D., F.R.S.

5. Eight Lectures on the Psychology of Conduct. By William MacDougall,
M.A., M.D., F.R.S.

6. Twelve Clinical Demonstrations in Neurology. By F. Golla, M.D., F.R.C.P.,
and Sir Frederick Mott, K.B.E., M.D., F.R.S.

7. Six Lectures on the Psychoneuroses. By Bernard Hart, M.D. (Physician
Mental Disease University College Hospital, Lecturer in Mental Disease,
University of London).

Fees.

For the Whole Course of Part I and Part II
For Part I separately ....

For Part II separately ....

For either Group 1 or Group 2 of Part II

(Group 1 consists of Sessions 1, 2, 3, 4; Group 2 consists of Sessions 5, 6 and 7.)

Applications for forms of admission to the Course should be made to the
Asylums Officer, 13, Arundel Street, Strand, W.C. 2.

The Fellowship of Medicine, 1, Wimpole Street, W., will collect fees from, and
issue admission tickets to, medical men intending to take the course, who are
introduced by the Fellowship.

LIBRARY FOR DEAF EDUCATION.

In connection with the Ellis Llwyd Jones Lectureship for Training Teachers of
the Deaf, recently established at the University of Manchester through the bene¬
faction of Sir James E. Jones, the Carnegie United Kingdom Trust has generously
granted to the University the sum of .£2,500 for the foundation and maintenance
of a Library for Deaf Education. It is intended to make this Library as compre¬
hensive as possible, and to include in it works dealing with the various systems
of teaching the deaf—speech training, psychology of speech and hearing, phonetics,
acoustics, anatomy, physiology, and diseases of the ear. The books are to be
available to all individuals, societies and institutions throughout the United
Kingdom interested or concerned in the education and training of the deaf, and
they will be ready for consultation and borrowing immediately after Easter, 1920.

No charge, beyond the cost of carriage, is made for the loan of books, but
intending borrowers are required to fill in a form of application to be obtained
from “The Librarian, Library for Deaf Education, The University, Manchester,”

(Signed) Cbas. Lbigh,

Librarian.

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OBITUARY.

Dr. Edwin Lindsay Dunn,

Late Medical Superintendent of the Berkshire Asylum , Wallingford .

I feel great diffidence in writing the obituary notice of Edwin Lindsay Dunn,
for I realise how inadequate is my pen to do full justice to the task. The son of
the late Mr. Robert Dunn, of Dunfield, Waterside, Ireland, he was born in 1865
and received his early education at Foyle College, Londonderry, winning a scholar¬
ship in 1876. The examiner on that occasion was Mr. J. H. M. Campbell, then
Scholar and Senior Moderator of Trinity College, Dublin, who reported on “the
splendid answering in every subject of Dunn.” He thus gave evidence, even at so
tender an age, of those remarkable talents which characterised his more mature
years. His school career was throughout most brilliant, and after being an Inter¬
mediate Exhibitioner 1879-1880 and a Matriculation Exhibitioner, R.U.I., 1881,
he entered Trinity College, Dublin, as First Junior Exhibitioner in 1882. There
he continued his successful career, taking his B.A. degree with Honours in Classics
and English Literature. He then decided upon medicine as a profession, and after
taking Honours in Anatomy, and incidentally holding the posts of Resident Pupil,
Dr. Steevens’ Hospital, Dublin, Clinical Clerk and Surgical Dresser, Sir P. Dun’s
Hospital, Dublin, and Prosector to the University Anatomist, he received the
degrees of M.B., B.Ch. in 1887. He was later appointed Assistant House-Surgeon
to the Children’s Infirmary, Liverpool, Assistant Surgeon, Liverpool Dispensaries,
and, upon adopting lunacy practice as a career, Assistant Medical Officer at the
West Riding Asylum, Wakefield. At Wakefield Asylum he made several con¬
tributions to medical literature, including “Cases of Epilepsy Treated by Amylene
Hydrate,” “Case of Softening of the Sensory Tract of Internal Capsule,” and
41 Case of Homonymous Hemianopsia.” Dunn’s paper on “ Paranoia,” read at the
Psychology Section of the British Medical Association at Nottingham in July, 1892,
was a noteworthy addition to our knowledge of that disease, although cases had
been recognised in England before then. He was a member of the Medico-Psycho¬
logical Association, a member of many years 1 standing of the British Medical
Association, and a prominent member of the Reading Pathological Society. He
was appointed Senior Assistant Medical Officer and Deputy Medical Superintendent
of the Berkshire Asylum, Wallingford, in 1894, and on the death of Dr. Murdoch
succeeded him as Medical Superintendent.

Outside his professional work, literature, Freemasonry and sport appealed most
to him. At school he was a member of the Fifteen and a good runner, at Trinity
College, Dublin, a prominent oarsman, rowing for the University Boat Club and
winning many races, and a member of the University Fifteen. He also played for
the famous Wanderers Club, but although well in the running for Internationa]
honours was not capped for Ireland—a fact which always caused him keen regret.
He was fond of shooting and golf, and a good fisherman, his proudest trophy being
a fine Thames trout, scaling 74 lbs., which he caught at Pangbourne.

Dunn was an enthusiastic Freemason, and was installed Worshipful Master of the
St. Hilda Lodge, Wallingford, in 1890. He excelled as a raconteur and after-
dinner speaker, and a speech he once made in aid of the Masonic Charities will live
in the history of the St. Hilda Lodge.

He was extremely well-read, and could talk with knowledge, and in his own
delightfully original way, on any subject. Politics, religion—his knowledge of the
Bible was profound—science, sport, literature, nothing came amiss to him. He
read Greek for pleasure, and was very fond of French literature.

He was a true Irishman, genial, quick-tempered, impulsive, generous to a fault,
the soul of hospitality, extremely witty, excellent at repartee. I remember his
once being stopped in Oxford by a particularly dirty tramp, who tried to sell him a
cake of soap, and Dunn’s reply, “ I’m afraid you can’t spare it, my man, but here’s
twopence for you.” His laugh, apart from his sunny disposition and high spirits,
was the most infectious thing about him. No one who ever heard it could readily
forget it. He had a genius for making friends and for keeping them, and his red
jovial face, merry blue eye and inimitable laugh will be sadly missed. The Visit¬
ing Committee of the Asylum were his personal friends; he was beloved by his
patients and staff, to whom his sympathy, advice and help were always open.

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A devoted son and brother, his mother’s death a few years ago was a great blow
to him. His own death occurred on January 12th, after several weeks of great
pain and suffering borne with wonderful patience and fortitude. He was un¬
married. He leaves a sister to mourn his loss, and to her I am indebted for much
of the information here recorded. P. C. Coombes.

Dr. J. Barfield Adams.

The short illness and sudden death, at the age of sixty, of Dr. J. Barfield Adams
on February 20th, 1920, while returning from some professional call, came as a great
shock to his medical brethren in North Bristol, where he had practised in general
medicine for over thirty-five years. About eight years previously he had had to
take a rare and enforced holiday in Holland and Belgium and Northern France
owing to a first attack of angina pectoris, but he returned to his duties quite as
devotedly and almost as strenuously as before, and carried on ever since. Though
he had repeated warnings of the same kind, and his heart must have latterly begun
to fail seriously, none of us who saw him in the last few weeks and even on the day
of his death, going about much as usual, had any suspicion of impending danger;
the more so as he had always been a man of great reserve where he himself was
personally concerned.

He received his medical education in the Edinburgh University and Extra
Mural Medical School, and obtained the Edinburgh Triple Qualification in 1882.
From the interest he took and the knowledge he displayed in matters medico-
psychological I think he must have had asylum experience, though I have no
record as yet as to where he did duty. For the last dozen years he held the respon¬
sible post of Medical Officer to the Bristol Colston’s Girls’ School. He became a
member of the Medico-Psychological Association in 1913, and about the same time
obtained the Certificate in Psychological Medicine of the Association. While his
chosen life-work was to be a general medical practitioner of the best type, he was
one of these medical men (all too few as yet) who take an intense interest in
psychiatry as bearing on their daily work in medicine. Long and happily married,
he left no children to mourn his loss.

In the last few years, and more especially during the war, he undertook regular
work for the Journal of Mental Science , and contributed valuable critical epitomes
of current medico-psychological literature, irradiating his views with sympathy,
humour, and occasionally with gentle dissent. Himself a literary artist and a
master of style, he also contributed two original delightful critical studies to the
Journal of Mental Science , namely 11 Zola’s Study of Heredity ” (July, 1916), and a
complemental ” Zola’s Studies in Mental Disease ” (April, 1917). A discriminating
admirer of one whom he dubbed “ Master,” he freely points out where he thinks
Zola failed to be quite true to nature in some of his cameos of insane and degene¬
rate characters. In a third contribution to the Journal, <f The Orientation of
Human and Animal Figures in Art” (October, 1917), he successfully broke new
ground, revealing a wealth of erudition and a playfulness of humour worthy of
De Quincy, combined with an insight into pictorial art, and a personal acquaintance-
with experimental pedagogics quite remarkable. In the same vein about the
same time he contributed two essays on Zola to other journals entitled “ The
Doctors in Zola’s History of the Rougon-Mackquart Family,” and “ Dr. Pascal
Rougon : Zola’s Study of a Savant.”

He told me once that alter graduating he had toured on a bicycle throughout the -
highways and bye-ways of Northern France, with a view mainly to a study of
French ecclesiastical architecture. Each cathedral was to him no mere local lion,
but an organic whole, showing in the details of its structure within and without its
own particular history and that of the ages it had weathered. He was a finished
French scholar both in speech and in literary knowledge. In later years he took
up the study of Italian (” The Doctors in the Decameron ”), Spanish, and even
Welsh (” Medicine and Surgery in the Mabimogion ”). Whether he ever studied the
11 gentle German language ” is not very apparent; if he did (as is possible) he
allowed no pestilent whiff of latter-day Teutonic kultur to obscure his clear vision.
into Gallic esprit .

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1920.]

He took great pleasure in studying what Charles Reade called the “ poor dear
doctors’ 1 themselves (and incidentally some of their patients) as mirrored in
literature, and more especially in that of his beloved France.

Others (friends and patients of this quiet, many-sided man), who knew him more
intimately, could doubtless say much of him from their several points of view. It
suffices here to say that to those of us, his professional brethren, who met him only
occasionally on our daily rounds, he was a dignified, kindly man of the highest
personal and professional ideals, wise in counsel, and a stimulating listener, who in
any subject of conversation was willingly allowed to make the deciding judgment.
One might apply to him the remarks he makes himself on one of his favourite
characters in Zola, “ the savant,” Dr. Pascal Rougon: “ He had a profound
contempt for all that was mean or ignoble—the few who were admitted to his
friendship loved him for his honesty and goodness of heart, and admired him for
his devotion to work.” W. Cotton.

Dr. Elmer E. Southard,

Bullard Professor of Neuropathology , Harvard Medical School.

The death in New York on February 8th, 1920, from pneumonia after an illness
of two days of Dr. Elmer E. Southard, of Cambridge, America, will be learned with
much regret by readers of the Journal and members generally of the Medico-
Psychological Association.

Dr. Southard was born in Boston on July 28th, 1876, and graduated in Arts
at Harvard College in 1897, and at Harvard Medical School in 1902. After
studying at Frankfort and Heidelburg he entered the City Hospital, Boston, as
Interne and Assistant in Pathology in 1901, and three years later he became
Instructor of Neuropathology at the Harvard Medical School. In 1906 he
became Assistant Physician and Pathologist of the Danvers State Hospital,
and in 1909 he was made Bullard Professor of Neuropathology at the Harvard
Medical School and appointed Pathologist to the Massachusetts State Board
of Insanity. Since 1912 he had been Director of the Boston Psychopathic
Hospital. He was also Pathologist to the Massachusetts Commission on Mental
Diseases. He was associate editor of the Journal of Nervous and Mental Diseases
and assistant editor of Epilepsia. In 1917 he was attached to George Washington
University, and during the war was a major in the Chemical Warfare Service.

He collaborated in the production of a recent work on Shell Shock and Neuro¬
psychiatry , and made many valuable contributions on neuropathology and mental
hygiene to current American psychiatry, and his wide knowledge and influence as
regards these and allied subjects were recognised both at home and abroad.

The respect and trust his countrymen reposed in him is shown by the fact that
he was a member of the Board of Associated Charities of Boston and of the
American Academy of Arts and Sciences. He had been President of the Boston
Society of Psychiatry and Neurology and President of the American Medico-
Psychological Association.

He was stricken when fulfilling a series of important engagements before several
medical bodies, and the day before had addressed the National Committee for
Mental Hygiene at the Academy of Medicine, New York.

He was one of America’s foremost amateur chess players and a member of St.
Botolph and Boston Chess Clubs.

His loss was much mourned in America, and the memorial service held at
Appleton Chapel, Cambridge, was attended by Harvard professors, students,
members of the State Board of Health, and many others. He had reached the
stage of maturity and greatest usefulness, and a brilliant future was before
him. His great patterns were Prof. Royce and Prof. James, whose ideals were
reflected in much that he did. An enthusiastic writer, with a cheerful and attractive
personality, his whole thought was how best to serve humanity. It is for others
now to continue in his footsteps, and his many friends and admirers, who owe so
much to him, will see that his teachings are not lost to posterity but continued and
amplified as if he were yet with them.

His helpmate in life was Dr. Mabel Fletcher Austin of Boston, whom he married
in 1906. J.R. U.

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[April, 1920.

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NOTICES OF MEETINGS.

Annual Meeting.

The Buxton Town Council have officially invited the Association to hold their
Annual Meeting there this year, and the following is a short summary of the
arrangements made:

Monday , July 26th .—Committees meet as early after lunch as members can arrive.

Tuesday, 27 th .—Spent at Cheddleton. Committees, Council, etc., at no a.m.
Lunch for ladies and members x p.m. Annual Meeting 2 p.m. Visit to silk mill
at Leek or to pottery at Hanley in forenoon. Garden party 3.30 p.m. Annual
Dinner, Buxton (members and ladies), 8.30. Motor char-a-bancs will be arranged
for. Buxton to Leek 12 miles, south (rise and fall of over 1,500 ft. between),
Leek to Cheddleton 3 miles, south.

Wednesday , 28 th .—Scientific discussions, Town Hall, Buxton, 10 a.m. Half¬
day excursion for ladies in the forenoon. A reception may be arranged in the
Town Gardens for the afternoon.

Thursday , 29 th, —Full-day excursion to Haddon Hall and Chatsworth. If more
papers are promised, so that a meeting on Thursday morning becomes desirable,
half-day excursion will be arranged for Thursday afternoon, and the Haddon Hall
excursion on Friday if members will stay, in view of the fact that the following
Monday is Bank Holiday.

HOTEL ARRANGEMENTS should be made at Buxton at once , as the end of
July is the height of the local season and lodgings become unobtainable.

The following hotel accommodation at Buxton is recommended: Palace Hotel,
Crescent Hotel, St. Ann’s Hotel, Buxton Hydro, Haddon Hall Hydro, Olivers
Hydro, Sandringham Hotel, Milton House, Old Hall Hotel, Shakespeare Hotel,
Pendennis, George Hotel, Pavilion.

Divisional Meetings.

South-Eastern Division .—May 5th, Littleton Hall, Brentwood, Essex.

South-Western Division .—April 23rd, Portsmouth Mental Hospital.

Northern and Midland Division .—April 29th, Mental Hospital, Middlesbrough.

Irish Division .—June 24th and November 4th, 1920 ; April 7th, 1921; July 7th,
1921.

NOTICE BY REGISTRAR.

Dates of Examination for Nursing Certificates .

May 3rd.Preliminary.

„ 10th.Final.

REVIEWS.

The Editors regret that the notices of the Report of the Board of Control and
Mental Hospitals and Asylums Reports generally are again unavoidably postponed.

NOTICE TO CONTRIBUTORS.

N.B .—The Editors will be glad to receive contributions of interest, clinical
records, etc., from members (whether these have been read at meetings or not)
for publication in the Journal. They will also feel obliged if contributors will
send in their papers at as early a date as possible in each quarter.

Writers are reminded that, according to lix(<z) of the Articles of Association,
11 all papers read at the Annual, General, or Divisional Meetings of the Association
shall be the property of the Association, unless the author shall have previously
obtained the written consent of the Editors to the contrary.”

Papers read at Association Meetings should not , therefore , be published in other
Journals without such sanction having been previously granted.

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THE

JOURNAL OF MENTAL SCIENCE

[.Published by Authority of the Medico-Psychological Association
of Great Britain and Ireland .]

No. 274 [X'ST] JULY, ! 920. VOL. LXVI.

Part I.—Original Articles.

The First Maudsley Lecture, delivered by Sir James Crichton-
Browne, D.Sc.Leeds, M.D.Edin., Hon. LL.D.St.And. and
Aberd., F.R.S.Lond. and Edin., Lord Chancellor’s Visitor in
Lunacy, at the Quarterly Meeting of the Medico-Psychological
Association of Great Britain and Ireland, held at the House of the
Royal Society of Medicine, London, on May 20th, 1920.

Gentlemen, —I feel I owe the honour of having been selected to
deliver this first Maudsley Lecture, not to any special fitness I possess
to expone any of the more recent developments of that branch of
medicine, the furtherance of which the lectureship is intended to pro¬
mote, but to the fact that I am almost the last survivor of those who
were associated with the founder of the lectureship in the early days of
his professional career. While still a student at the University, Maudsley
was revealed to me in a brilliant essay on Edgar Allan Poe, which was
published in the Journal of Mental Science in April, i860, and which,
although too scathing and denunciatory of the ill-fated poet, as it now
appears, was so rich in insight, originality and happy similitudes as to
betoken unmistakably “ the lighting of another taper at Heaven,” which
was at that time Maudsley’s way of describing the arrival of a new man
of genius on the scene. A few years later I made Maudsley’s personal
acquaintance at the table of that gracefully-refined and highly-gifted
physician and philanthropist. Dr. John Conolly, who afterwards became
his father-in-law, and in the years following I can recall many
memorable meetings with him at “ The Lawn,” at Hanwell, in his rooms
in Queen Anne Street, and in a restaurant in Soho, where, over frugal
meals, he and I and Lockhart Robertson, and Broadbent and
Harrington Tuke and Baron Mundy of Moravia, the zealous advocate
of non-sequestration and family life and free air for the insane, held
high discourse and adumbrated projects for the future of lunacy, some
LXVI.

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of which have taken shape since then, while others remain unrealised
and perhaps unrealisable.

Maudsley’s pathway and mine diverged physically after these racy
and roseate London days, when my lot was cast in the provinces for a
decade, and they diverged spiritually also, for he abandoned the
teleological platform on which we both started and advanced into
scientific materialism and agnosticism, where I could not then follow
him. But whatever differences of conviction and outlook separated us,
our friendship remained unbroken to the end. I cannot claim to have
been one of what was, I believe, the very small circle of his intimates,
but I was never estranged from him by quarrel or misunderstanding,
and the admiration and esteem in which I held him never for a moment
paled.

I have not the material for even a biographical sketch of Maudsley if
I desired to present one to you, and any such sketch would be of only
ephemeral and partial interest, for we shall, I trust, have, one of these
days, an adequate record of a life prosperous and uneventful, but rich
in fruitful endeavour and leaving a distinctive mark on the philosophical
history of the latter half of the nineteenth century. An appreciation of
Maudsley’s achievements such as the time-limit here would permit is
still less feasible, and would be somewhat superfluous after the generous
and sympathetic but discriminating obituary notices which we owe to
Sir George Savage and Sir Frederick Mott, and would, moreover, be
out of place, for I am sure the last thing the donor of this lectureship,
retiring and shy of publicity as he was, would have wished would be
that its inaugural discourse should be devoted to any elaborate eulogy
of himself. Let me just say of him that in every situation in life, in the
domestic circle, in society, in the lecture-room, by the bedside] and in
the witness-box he “ gave the world assurance of a man,” and of a man
of a striking and unique personality, of keen and decisive intellect, and
of a courageous and independent temper. Of tough Yorkshire fibre,
deftly woven, Maudsley had in him a dash of the gloom and austerity
of “ Wuthering Heights,” but that was lit up by the sunshine of a liberal
culture and by genuine goodness of heart. He was cynical and
sententious betimes, but the tartness of his tongue was belied by his
genial smile, and the pessimism he preached was discounted by the
charity he practised. Enemies he had, for he had no tolerance of fools,
and was swift to castigate presumption and pretence. Dissentients
from his teaching there were and must be many, for the sanguine revolt
from the cheerless creed of man’s helplessness and Nature’s indifference,
but on all hands he must be acknowledged as a force making for
rectitude that powerfully affected the time in which he lived and that
must far into the future stimulate the thoughts of man.

To discuss Maudsley’s contributions to the physiology and pathology

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of mind, which must constitute his great claim on the consideration of
posterity, to disentangle what in these he derived from others—such as
Herbert Spencer and Laycock and Van der Kolk and Morel and
Darwin and Carlyle and Emerson—from his own acute observations
and cogent reflections, would be an intricate task upon which I do not
propose to enter, but in connection with the whole legacy he has
bequeathed to mankind I would wish to say a few words about that
portion of it which appertains to this lectureship and to the hospital
which is to bear his name. It was no monumental craving, I am sure,
that moved him to the endowment of either the one or the other, but
an earnest desire to advance the interests of that special department of
medicine which he had served so faithfully and to reduce the mass of
human suffering.

In the lecture, which is to be alternately scientific and popular, he has
devised a much-needed means of maintaining and extending the scope
and usefulness of the Medico-Psychological Association, for the building
up of which he did so much, and of conveying to those who stand
outside our specialty and to the public generally some little knowledge
of the work it is accomplishing. The nature of the medium in which
we work and the legal restrictions under which that work is carried on
have in the past kept us to some extent aloof from the main body of
our profession, and but little has been known by the world at large of
the polity of those somewhat insulated “ cities of the simple ” that now
in such numbers stud the land. The consequence is that gross mis¬
conceptions of our status and performances are prevalent in some
quarters, misconceptions to which we have ourselves in some measure
contributed by our proclamation of grievances and calls for reforms,
and to which, perhaps, the Maudsley lecture may prove henceforth an
annual antidote.

Quite recently, in a book that has obtained wide circulation, Prof.
Eliot Smith has drawn a painful picture of our situation. We are, it
appears, backward and negligent to a shocking degree. The ignorance
of our asylum medical officers of up-to-date knowledge in psychiatry is
deplorable. Research is non-existent, our text-books are contemptible,
our system of treatment does not conduce to recovery, and America,
France, Germany and Switzerland have long ago faced the problems of
mental disease which we have shirked.

Now Prof. Eliot Smith is, I know, zealous of many good works, and
is no doubt eager to promote the best interests of the insane, but
his attack on our specialty is, I venture to say, unjust and ill-informed,
and it is evident that before making it he has not fully acquainted him¬
self with the history of psychological medicine or with the writings of
the founder of this lectureship and of contemporary alienists. I would
recommend to him a careful study of the sixty-six volumes of the

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Journal of Mental Science, and I am confident he will rise from their
perusal satisfied that asylum medical officers have not lagged behind
their profession generally, but have, in proportion to their number, and
having regard to the arduous and time-absorbing routine duties
imposed on them, produced more than their fair quota of sound, pains¬
taking, progressive, scientific work. As regards the humane treatment
of the insane, the nature of the asylum provision made for them, the
investigation of their condition—psychical and corporeal—and the
employment of remedies, medical and moral, for their relief, this country
has nothing to fear from comparison with any other. In every march
forward she has led the van. We are exhorted to look with envy at the
spacious and well-appointed research laboratories attached to some
asylums in Germany, and no doubt in that direction we have been
somewhat distanced by developments in Germany and the United
States, but it should be borne in mind that the first asylum research
laboratory in Europe—small and humble it was, but still a research
laboratory, in which experiments of high and permanent value were
conducted—was established in connection with an asylum in England
more than fifty years ago. Our Scottish asylums have been co-operating
in laboratory work for thirty years, and in several asylums in England
and Wales well-equipped laboratories exist which, now that the war is
over, may be expected to yield a rich harvest.

No doubt in our department changes and reforms are necessary, but
we have been the first to acknowledge it and to press for action. Greater
freedom is needed in meeting the manifold requirements of a protean
disease. Some archaic legal fetters should be struck off, the medical
staff in some of our large asylums should be reinforced and more
liberally remunerated, and, above all, facilities should be afforded for
the early treatment of cases of mental disorder, incipient in character
or of recent origin. But the necessity for early treatment under such
circumstances, the advantage of which has been so conspicuously
demonstrated in the psycho-neuroses of the war, is no new discovery.
You can scarcely open any asylum report for the last fifty years without
finding in it expressions of regret that the patients admitted have not
been more promptly dealt with, and statistical evidence that the
prospect of recovery is in the inverse ratio of the duration of the
insanity prior to removal to the asylum. There can be no question
that the legal formalities connected with asylum treatment, intended
for the protection of the liberty of the subject, have led to some
increase of insanity, or rather accumulation of lunatics. There has
been a natural shrinking from certification, magisterial inspection and
registration as a lunatic or person of unsound mind, and from all the
vexatious limitations that attend detention in an asylum, with the
stigma that it is supposed to leave behind it, and so the evil day has been

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in many cases postponed as long as possible ; the golden opportunity
has been allowed to slip past unimproved, and what might have been a
transitory illness has been converted into a permanent infirmity.

It was in the hope of avoiding such calamities, and of furnishing
opportunities for the early treatment of cases of acute and recent
mental disorder, while at the same time promoting pathological investi¬
gations and the education of medical students and medical practitioners
in psychology, that Maudsley generously supplied the funds for the
hospital which now stands on Denmark Hill, admirably equipped, and
happily under the sagacious tutelage of Sir Frederick Mott. It was in
1907 that the scheme occurred to him, but long before that the want
of such an institution had been felt and insisted on, and I hope I shall
not be regarded as egotistical if, in order to show that we have not been
as blind and sluggish as is alleged, I quote a passage from the Presi¬
dential address which I delivered to the Medical Society of London in
October, 1895 : “For my own part,” I said, “my hopes are centred in
the establishment in or near London of one or more, not asylums, but
genuine hospitals for mental disease. These hospitals would be
organised like ordinary general hospitals, would have a staff of visiting
and assistant physicians, and of consulting surgeons, and specialists in
diseases of the eye and ear and in those peculiar to women, and of
resident medical officers and clinical clerks. Attached to them there
would be an out-patients’ department and a school of medical psy¬
chology with laboratories and museums, in which systematic investiga¬
tion, teaching and demonstration would be carried on. A few such
hospitals—not merely ‘ monasteries for the mad ’ or convenient shoots
for human rubbish, but real mental hospitals—would exercise at once a
salutary and invigorating effect on the medico-psychological specialty
and bring it back into closer correspondence with the medical profession
as a whole.”

That vision has in part materialised in the Maudsley Hospital, and
the Maudsley Hospital has set an example which will be followed under
the more liberal and elastic lunacy law dispensation which is undoubtedly
in store for us. Hospitals like it will spring up in our large towns, and
pyschiatric clinics will be established in connection with our general
hospitals, where sufferers from mild and larval insanity may receive
skilled treatment in conjunction with patients suffering from purely
nervous affections without incurring the odium of having been in an
asylum. There will be an extension of the out-patient department in
our public asylums and a perfecting of their clinical apparatus, for it is
in them, however successful early hospital treatment may be, that an
enormous majority of the insane will still be lodged and treated.

That early treatment will be successful in intercepting some part of
the stream of the mentally deranged that now flows on so copiously to

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our asylums cannot be doubted, but exaggerated notions of the benefits
that will acrue from it should not be entertained. The main part of the
stream setting towards asylums consists of congenital idiots and
imbeciles, of general paralytics and chronic epileptics, of confirmed
cases of dementia prsecox or paranoia, and of patients labouring under
organic and senile dementia, for whom treatment, early or late, will be
of little avail, and there must always be included in that stream a
certain proportion of recent and acute cases in which dangerous pro¬
pensities render immediate admission to an asylum necessary. Already
too recent and acute mental disorders occurring in persons belonging to
the upper and middle ranks have had the benefit of early treatment
and highly skilled advice by specialist physicians, while in all ranks
such disorders have been and are successfully grappled with to some
extent by the capable general practitioner, who nowadays knows
enough of insanity not to be afraid to touch it, and who in the near
future, it is to be hoped, will be so educated as to be able to deal with it
secundum artem. Altogether the relief afforded by early treatment to
the pressure on our asylums will not be as great as has perhaps been
anticipated. The special mental hospitals, psychiatric clinics and
mental nursing homes that come into being under the new regime will
be auxiliary to our asylums, but they can in no degree supersede them,
and it would be a misfortune if they derogated in any way from the
reputation of our asylums as curative institutions. Our asylums must
become hospitals more and more, and more and more there must be
enlisted in their service men of high professional and scientific attain¬
ments. There will always be scope in them for the exercise of the
finest qualities of head and heart, of expert discernment, and of the
healing art, and for experimental inquiry as interesting and promising
as that pursued in psychiatric laboratories. Abundance of fresh
material is ever pouring into them, and there is, unhappily, piled up in
them a huge heap of human dibris that will reward sifting over from time
to time. Nothing in my official experience has struck me more than the
way in which cases of insanity of long standing and labelled “ chronic ”
have unexpectedly recovered. And apart from any prospect of
recovery, chronic cases of insanity are deserving of scientific attention
and ministration. “ It is not beneath the dignity of a medical man,”'
to quote the words of Macaulay, “ to contrive an improved garden
chair for a valetudinarian, to devise some new way of rendering his
medicine more palatable, to invent repasts which he might enjoy,
and pillows on which he might sleep more soundly: and this though
there might not be the smallest hope that the mind of the poor invalid
would ever rise to the contemplation of the ideal beautiful and the
ideal good.”

With the view of insuring that our asylums shall, to the utmost.

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fulfil their diverse functions, it is proposed that henceforth those
holding in them the higher medical posts should possess a diploma in
psychological medicine representing a curriculum of special studies
and an examination thereon. The proposal has much to recommend it,
but I confess I hope it will not be too rigidly interpreted. In general
medicine the asylum medical officer cannot be too proficient, and in
the anatomy, physiology, and pathology of the nervous system he
must have more than the current modicum of knowledge, but as regards
psychiatry in the technical sense I am not quite sure that any great
length of time should be devoted to its academic study outside the
asylum. Of course a general acquaintance with its terms and methods
is desirable, but everyone, lay or medical, acquires some acquaintance
with psychology in his passage through life, and it is in the wards of
the asylum, in the school of experience, that a man must pick up
his practical psychiatry. In the treatment of insanity—in asylums at
any rate—it is the physical conditions underlying the disease and its
corporeal concomitants that should receive primary attention, and any
man endowed with nous and sympathy, the universal solvent, will soon
in his practice acquire a competent acquaintance with mental operations
in their normal and abnormal manifestations. I can conceive of a man
learned in all the wisdom of the psychologians who would be a less
successful asylum medical officer than one with quick insight, whole¬
some imagination and vivid sympathy who altogether ignored Freud
and Hegel. There is a tactus erudites in handling the morbid mind
that only personal practice can confer. Laboratory methods, as Sir
James Mackenzie has pointed out in reference to bodily disease, in¬
valuable as they are in their proper place, can never, in clinical medicine,
supplant the use of the unaided but trained senses, and may even lead
astray, and so in mental medicine psycho-analytical procedures in their
more intricate applications, interesting and suggestive as they are, can
never, I believe, yield that all-round information and pilotage which
methods of observation, long in use, can, when diligently employed,
supply, and may even involve the oversight of significant facts.

That the adoption in our asylums of every new means of alleviation
and cure which modem science suggests, and in our mental hospitals
and psychiatric clinics of prompt and efficient treatment in early cases
of mental trouble, will have eminently beneficial results cannot be
questioned, but it is, as I have hinted, to neither of these that we must
look for a material reduction in the load of lunacy under which we
groan. In order to secure that we must apply ourselves to the con¬
ditions out of which lunacy grows, and by the curtailment or removal
of these prevent its occurrence.

The recently published report upon the physical examination of men
of military age by National Service Medical Boards during the last year

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of the war presents us with what the Committee themselves describe as
“ ugly facts," revealing the altogether unexpected extent of the inroads
upon the health and physique of our manhood which the progress of
civilisation in the nineteenth century has brought in its train. Of the
2,425,184 men examined only 871,769, or 36 per cent., were placed in
Grade 1, corresponding with a normal and very moderate standard of
health and strength for their age, while 1,553,415, or 64 per cent., were
classed in the three lower grades, corresponding with different degrees
of physical shortcoming or defect down to permanent unfitness.

The causes of unfitness enumerated in the report, which range from
poor physique and hammer-toe up to advanced tuberculosis and valvular
heart disease, include insanity and mental defect, but afford no in¬
dication of the prevalence of these in the adult population. The
certificated insane and the recognised mentally defective were, of
course, excluded from the purview of the report, and it is notorious
that considerable numbers of lunatics and imbeciles did pass into the
army undetected. Among the volunteers who flocked to the colours in
the enthusiasm of the early days of the war were many men of unsound
mind who slipped through the then cursory examination, some of whom
“ foremost fighting fell,” and many of whom have been sent back to find
their ultimate destination in our asylums; and amongst the men who
passed through the stricter scrutiny established under the Army Service
Acts were many who laboured under disabling mental deficiency. The
examination of the National Service Medical Boards was essentially
physical, and practically no mental tests were applied except where
signs of mental weakness were ostensible, and then the tests consisted
in ascertaining what standard at school had been reached and what
wages had been earned, or by setting a simple sum in arithmetic. I
believe that many mentally deficient lads of fair physique, able to do
everything directed by the doctor, were graded 1, until there came a
letter of expostulation from a father or a belated medical certificate
relating facts necessitating rejection.

Had an examination been held into the mental condition of the men
coming before the National Service Medical Boards, at all comparable in
thoroughness and minuteness with that instituted into their physical
condition, and had that examination been conducted by experts, it
would, I am confident, have shown an amount of mental unfitness in
our adult male population—that is to say, in the sanest section of our
community—that would be startling, and would corroborate the finding
of the Ministry of National Service Committee that a grave emergency
exists. Were a psycho-census of the whole people practicable we should
undoubtedly have brought to light in all classes of society an unsurmised
amount of mental deficiency or disorder of one kind or another, and a
wide diffusion of that neurotic temperament that is the soil in which

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the neuroses and pyschoses alike grow. Our mental grade i in such a
census, including average intelligence, the absence of minor mental
defects and general fitness to meet the obligations of life, would be
small and select, and the other grades, corresponding with partial fitness
only, would be made up of heterogeneous masses of mental inefficiency
very unequally distributed in different areas of the country and industrial
centres.

We need not, however, wait for any psycho-census before insisting on
measures being taken for the mental betterment of our people. The
physical returns already before us are sufficient to warrant an immediate
resort to these. Even from the returns of stature alone we might infer,
having regard to the co-relation between height and mental ability, that
there is some general deterioration of mental energy, and the lists of
the causes for which men were rejected or low-graded reveal a multi¬
plicity of morbid physical conditions with which mental disability is
associated or on which it will become engrafted. It is impossible to
regard either the standards of height or of health as satisfactory, and we
may well be surprised, to quote the words of the committee, “ that with
human material of such physique it was found possible to create the
armies which overthrew the Germans and proved invincible in every
theatre of the war.” But the spirit of the race which made that possible
deserves that no efforts should be spared to ameliorate the conditions
which have brought about such deplorable effects upon its health and
physique.

One of the compensations we have for the war, with all its horrors
and anguish, is the discovery of our imperfections and of the risks we
have been running, the realisation of the urgent need of sanitary reform,
and the demonstration—the absolute demonstration—as set forth in
Sir John Goodwin’s recent Chadwick Lectures, of the infallible success
of sanitary precautions scientifically employed. We are awake at last,
and under the Ministry of Health, with its medical head, prompt steps
will be taken for the better housing of our people, with the re-con¬
stitution of family life that that will make possible, for their better and
unadulterated feeding, and for their physical training and protection
against over-fatigue, and for the restriction of the ravages of pre¬
ventable disease, and especially of venereal disease, which will all in
course of time be reflected in improvement in their mental vigour and
in their immunisation from certain forms of mental disease. These are
comprehensive hygienic measures of the need of which every member of
our department is profoundly convinced, and in the carrying out of
which they will all in their own sphere zealously co-operate ; but there
are other hygienic measures of a less material but still momentous
nature with which they are even more closely concerned, and on which
the founder of this Lectureship persistently dwelt. “ The prevention

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of insanity when possible,” wrote Maudsley, “ is a better thing than its
cure, which is often impossible.” And the two principal ways for its
prevention he laid down are to hinder its propagation from generation
to generation, and to employ that training and culture which is best
fitted to repress and suppress its germ in one who is predisposed to it.
Eugenics and education: these are the two great safeguards against
mental degeneration, disease, and decay.

An early eugenist, even before Galton invented the word, Maudsley
strongly advocated the main principles of the science. “ Were it the
rule,” he said, “ in the marriage mart, as in the horse mart, to require a
warranty of soundness, either many marriages would not take place
which now take place, or many actions for breach of warranty would
lie.” “ In the breeding of animals,” he said, “ we should unhesitatingly
discard stock wanting in the qualities which are the best characteristics
of the species. But mental balance and integrity is the highest attribute
of man, therefore all manifesting any lack of it should be for breeding
purposes discarded.” But to this sweeping generalisation he did not
consistently adhere. A believer in the transmission of acquired habits,
and holding that mankind is indebted for much of its progress to
genius, which has almost invariably emerged in families in which there
is a predisposition to insanity, he fell into what we should now regard
as grave error. “ To forbid the marriage of a person sprung from an
insanely disposed family,” he said, “ might be to deprive the world of
singular genius or talent, and so be an irreparable injury to the race of
men. Let it be supposed that a person will have children, one or more
of whom will go mad ; it might still happen that the world would gain
more by one of the children who did not go mad than it would lose by
those who did. In that case, would not this marriage, grievous as its
consequences might be to individuals, be amply justified by the good
done to the race ? Nature does not take much account of the individual
or his sufferings; it is singularly lavish in the production and destruc¬
tion of life. Of all the multitude of living germs produced, but an
infinitesimal proportion reaches maturity. If, then, one man of genius
were produced at the cost of one thousand or fifty thousand insane
persons, the result might be a compensation for the terrible cost.”

But the cost, we will now say, would be a good deal too high. In
the case assumed by Maudsley, the production of the mad folks would
be certain, but the appearance of the genius would be problematical;
genius is a rare commodity, and to encourage the marriage of persons
strongly predisposed to insanity on the off-chance of getting one genius
out of fifty thousand lunatics would be an exceedingly rash speculation.
The destruction of superfluous life by Nature takes place for the most
part at an early stage of existence. It is the living germs that are
sacrificed, and that sacrifice goes on abundantly in human beings; but

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209

lunatics are matured forms, and to sacrifice thousands of them to
lunacy in order to secure even a first-class genius would be ruinous.

Apart from this bit of homage to genius, Maudsley soundly enumerates
eugenic principles. He attaches primary importance to the insane
diathesis or an inborn tendency to emotivity which has played so
conspicuous a part in our war psychoses, he distinguishes the several
varieties of the neuroses which differ in degree and in liability to
herditary transmission, the transformations which they undergo in
passing from one generation to another, and their tendency to reappear
after skipping a generation, and he does all this with a charm of style
and a wealth of metaphor that make his teaching captivating and
impressive.

Since Maudsley’s time eugenics have advanced, and it is possible
now to speak positively on points which he left indefinite, but there is
still infinitely much to be done before a trustworthy code for practical
guidance can be constructed. It is still very often a perplexing problem
to know what to allow or forbid in the marriage mart. But the most
valuable contributions to our knowledge of eugenics in human relations
have come from our lunatic asylums and from the study of inebriates
and criminals, and it is to our lunatic asylums that we must look for
further guidance, now urgently required.

As regards mental deficiency, thanks to the labours of the Royal
Commission and to subsequent legislation, there has been reached
some popular recognition of the risks run and the restrictions and
segregation necessary, but beyond that all is licence and prohibition is
unknown. In the cultivated classes it is rarely that persons complating
union seek medical advice, and the proletariat marry and are given in
marriage without a thought of their physical or mental fitness for
parentage. During the war there has been much precipitate and
indiscriminate matrimony of a very short-sighted description, and
altogether it would be Utopian to hope for any speedy diminution of
insanity due to increased eugenic wisdom. But the eugenic propaganda
should be more active than ever, and the public mind should be
disabused of the notion that the doctors are the uncompromising
opponents of marriage wherever any tendency to insanity exists on
either side. It is theirs to weigh probabilities, and as often to abolish
unnecessary apprehensions as to warn against prospective evils. I
daresay it has happened to many of us to be consulted in fear and
trembling by the son or daughter of a general paralytic, bom long
before the infection leading up to that disease was contracted, who
would live for years haunted by misgivings but for the assurance which
the doctor is able to give.*

As regards education in connection with the prevention of insanity,
Maudsley took a broad and judicious view. "There are not many

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natures predisposed to insanity,” he said, “ but might be saved from it
were they placed in their earliest days in exactly those circumstances
and subjected to exactly that training most fitted to counteract the
innate infirmity.” And we may go further than that and affirm that
there are not many natures, whether predisposed to insanity or not,
that may not be fortified by genuine education against the attacks of
those malign agencies that are productive of mental disease, and that
are encountered by all men and women in their journeying through
life. All high-grade alloy steels owe their strength and shock-resisting
properties to scientific heat treatment, and so high-grade brains should
owe their tensile strength and shock-resisting power to the scientific
educational tempering they have undergone.

But scientific educational tempering which will brace the brain and
steady the mind and prove protective against adverse influences is yet
to come. Instruction we have had on the large scale, education to a
limited extent, and while instruction has conferred upon the country
enormous benefits, it has also been responsible for some disastrous
consequences where it has over-strained immature feeble and under¬
nourished brains, or has tended, under hare-brained teachers, to
unsettle these fundamental tenets of morality on which mental and
social stability depend. The seeds of insanity have sometimes been
sown in the school, and its first sproutings have taken place there
unnoticed. “ The loom of youth ” has left nasty flaws and introduced
distorted patterns into the fabrics it has woven and splendid opportuni¬
ties of promoting mental hygiene in our gymnasia have been wasted,
simply because our ruling educational authorities have in their self-
sufficiency ignored psychology and cerebral physiology. We are, I
think, becoming alive to that now. The attention bestowed on the
bodily health of the children since the appointment of school medical
officers has conduced to their mental welfare, and the weeding out of
the feeble-minded has led to the recognition of different degrees of
educability in those who are not technically defective.

But we are just entering on a new era in education and again we
have to thank the war for a drastic change. The new Education Act
has secured for this country, I believe, educational machinery superior
to that of any nation in the world, and it remains for us to put that
machinery to a right use. It has become obligatory to provide not only
a sound elementary or preparatory education for all, but to follow that
up by a further course, the type and extent of which, whether seconday,
technical or university, will be determined, not by social standing or
economic conditions, but in the first instance by the outlook and fore¬
thought of the parents, and in the second place by the ability and
inclinations of the students themselves. Our educational activities are
to be extended both upwards and downwards, and it is to be hoped

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that in their every stage they will be aided by medical and psycho¬
logical knowledge and experience.

In the nursery schools which are to be established some modifi¬
cations of the methods of Dr. Montessori—a distinguished member
of our specialty, whose system is founded on the work of another of our
confreres, Seguin—will certainly be adopted, and will help on infantile
mental evolution on right lines. In our elementary and secondary
schools expert assistance will have to be sought in adapting the
curriculum to brain growth, and in devising the best means of educing
the inborn capacities and faculties in different groups of boys and girls
at different ages, and in performing a duty in which schoolmasters and
teachers now lamentably fail and for which they are perhaps incom¬
petent, and that is to advise on the course of life and occupation for
which the boy or girl leaving school is best suited by talent, attain¬
ments and predilection, and in which he or she will find most satis¬
faction and success, thus avoiding the danger to mental equilibrium
which an uncongenial like-work entails. In schools of all ranks the
health ideal must be set up, dislodging the old fetish of book learning
with contempt for this vile body, as it used to be called, and in all, as
in the home circle, there must be initiation into the mysteries of life
and the inculcation of sound rules of wholesome living.

In order that education may be made fully effective in the prevention of
insanity and of its neurasthenic and hysterical harbingers much study
of the growing mind is still necessary, and that must be undertaken by
psychological experts, who will no doubt employ psycho-analysis—but
psycho-analysis of our old English type, chaste and approved, with no
admixture of German frightfulness, and in constant conjunction with
neuro-physiology. Much light has been thrown on the part which
education in its widest sense may play in the prevention of insanity,
and on the dangers that attend the lack of it—that is to say, the lack
of trained disciplinary control of the higher over the lower centres in
the nervous system by the psycho-neuroses which have arisen out of
the war; and some light is, I believe, thrown by these on the
mechanism of the brain and on its functional habits. Particularly
interesting in this respect have been those rapid transitions from states
of grave mental disorder and incapacity to restored power and normality
which have been of such frequent occurrence, which have, more than
any other mental war phenomena, interested the public, and which have,
of course, corresponded with sudden brain changes.

Now sudden brain changes are no new things. They have been
brought into prominence by the war, but they have occurred from time
immemorial, and, just as has been the case during the war, many of
the most striking instances recorded in the past have been in con¬
nection with speech and phonation. Herodotus tells us of a son of

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Croesus who had never been known to speak, but who, at the siege of
Sardis, was so overcome with astonishment at seeing the King, his
father, in danger of being slain by a Persian soldier, that he exclaimed
aloud, “ Oh, man, kill not Croesus! ” This was his first articulation,
but thereafter he retained his faculty of speech as long as he lived.
Dr. Wigan, the author of The Duality of the Mind, had a patient
eight years old, sound in intellect but perfectly dumb, and whose family
had abandoned all hope of curing him, who, seeing his father fall
overboard from a boat in the Thames, called out aloud, “Oh, save
him, save him! ” and from that moment spoke with almost as much
ease as his brothers. The late Dr. Charlton Bastian was consulted
about a boy—the son of a leading barrister—who had fits in infancy,
and who, when five years old, had not spoken a word. Two eminent
physicians were consulted about his dumbness but could not help him,
but before the end of another twelve months, on the occasion of an
accident to one of his favourite toys, he suddenly exclained, “ What a
pity 1 ” The same words could not be repeated, nor were others spoken
for two weeks, but thereafter he began to talk and soon became
exceedingly loquacious.

In cases like these there has been, we may presume, an arrest in
cerebral adjustment in one of its compartments. The age at which
articulate speech is acquired, or at which the receptive and motor
neurons concerned in it establish communication, varies considerably
in different individuals, and in cases such as those just mentioned had
been from some cause indefinitely postponed. But a powerful emotional
impulse, which is always of higher tension than a volition, ultimately
forced its way through the prepared, but hitherto untrodden, pathway,
and brought into relation those centres in which had been accumu¬
lated the memories of vocal sounds and those in which had been co¬
ordinated the complex movements of articulation. The channel, once
thus opened up, afterwards remained pervious.

But much more frequent than postponed is interrupted functioning
in certain cerebral tracts, and of that we have many different kinds, all
of which have been copiously represented during and since the war.
We have had not only mutism, but blindness, deafness, paralysis, con¬
tractures, amnesia and other mental derangements of instantaneous
incursion and sometimes capable of instantaneous cure.

Of the war neuroses, due to shell-shock—the term is objected to, but
I use it as short and convenient and now of pretty general acceptance
—of the war-neuroses due to shell-shock, those in which there has been
severe concussion or commotion cannot, of course, be terminated
abruptly except in death. In such cases ending fatally there have been
found minute scattered punctiform haemorrhages into the periadventitial
sheaths and substance of the brain similar to those seen in gas-poisoning,

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but in cases in which the concussion, actual or aerial, has been
less violent, and in which recovery has taken place, there has been
what might be called bruising of the delicate brain tissues. Of all
the lessons in neurology taught by the war there has been none more
striking than that showing the tendency to natural recovery in nerves
which have been concussed, compressed, lacerated, and even divided,
their recovery being sometimes delayed as long as ten or twelve weeks
after the injury. “ After a time,” says Dr. Macdonald, “ regeneration
commences in the lower end of the proximal segment, and new axon
cylinders grow down to and beyond the point of section. In from four
to six weeks there will be bundles of new axis cylinders at this point,
and if they are firmly tapped with the finger the patient will experience
tingling, or 'pins and needles,’ in the skin over the dorsum of the
foot. If the new axis cylinders succeed in growing down the trunk, or
if the latter has only been contused and has preserved its anatomical
continuity, then, pari passu with the growth of the axis cylinder, there
occurs a downward extension of the distal tingling on percussion.”

Now if similar recuperative changes occur in the neurons, axons,
dendrites or nerve-fibres of the brain which has been subjected to
contusion or compression, we can understand how gradual, although
perhaps long-delayed, resumption of cerebral function takes place where
that has been suspended more or less by shell-shock or other accident,
as in cases of anergic stupor. Under such circumstances sudden recovery
is not to be expected, either through reparative processes in injured parts
or by transference of function to intact areas, but the state of matters is
very different where there has been no coarse change in the cerebral
mechanism, but only that subtle interference with activity which we
call functional.

It is in cases of shell-shock where the physical injury has been slight,
or in cases where there has been no physical injury but merely strain
and stress, fatigue, or violent emotional perturbation, that there is
interruption in cerebral communication amenable to the immediate
re-establishment of continuity. It is in cases where psychogenesis has
been at work that sudden brain changes are most often observed, and
the psychogenetic conditions in such cases according to a certain school
are ascribed to conflicts between the standards of civilisation and a
body of imperfectly controlled and explosive forces in the subconscious
mind, the most common conflict being that between a sense of duty
and the instinct of self-preservation, immediate or deferred. We are
told that the war let loose horribly cruel, sadistic murderous impulses
which had been kept chained down during peace, and that is—as regards
our men, at any rate—I would say, a gross libel and a cruel insult to
those of us who have graves in France and Flanders to tend. As well
say that the operating surgeon is stirred by a latent taste for butchery.

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THE FIRST MAUDSLEY LECTURE,

[July,

No doubt in the heat of battle the combative iostinct and the instinct
of pursuit asserted themselves; no doubt now and again a man may
have given way to the lust of cruelty; but throughout the war I am
confident the mass of our men, under the most harrowing and revolting
circumstances, were animated and sustained by worthy motives and not
by subterranean devilry. Their heroism, their endurance, their help¬
fulness in the field, their unaffected stories, their merry jests, the letters
they wrote home, the poems they composed, prove this incontestably.
Even the bayonet exercise they went through, which is singled out as
pure savagery, was engaged in more, I believe, as a trial of skill than
with a blood-thirsty intent The herd-instinct of which we hear so
much may have helped to hold them together and impose restraint, but
it was patriotism pure and simple, and a sense of right and duty that
enabled them to accommodate themselves to the new assemblage of
strange and horribly trying circumstances in which they found themselves.
Our men went over the top, or suffered long-drawn-out misery in the
trenches, in no spirit of wanton aggression and brutality, but for self-
defence, for the protection of those united to them by family affection,
by friendly association, patriotic sentiment, or for righteous conviction.
The flame of modern knight-errantry was lambent amongst them.

That fear, or rather the fight against fear, and the inhibition of its
expression, have been largely accountable for our war psycho-neuroses
is indubitable, but that in no way impugns the courage of our troops,
for it is to be remembered that although the number of cases of psycho¬
neuroses has been large, the proportion of these to the number of men
serving has been exceedingly small, and that in almost all the cases
of psycho-neurosis thus originating there has been evidence of strong
psychopathic tendencies having existed before the war, or of that
neurotic temperament which corresponds with high susceptibility of
the higher nerve centres and diminished control of the higher over the
lower centres. The trend of modern civilisation seems to have been
to an extension of the dominion of man’s will in the higher or in¬
tellectual sphere, but to a reduction of its sway over lower corporeal
levels. North-American Indians and negroes have a control over the
reactions of painful and disagreeable stimuli which Europeans do not
possess. They can endure without wincing torture which would cause
in us the most lively manifestations of suffering, and I suppose it is true
that the coloured races engaged in the war have suffered less from
shell-shock than our men. Our great-grandfathers were probably harder
and less sensitive than we are to-day. The kind of neuroticism induced
by terror or protracted fear will depend on the direction in which
will-power, owing to inborn disposition, over-indulgence or habit is
weakest. The ascendancy of the will is not exerted along particular
lines as it ought to be, and so subordinate centres break away from

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authority and unduly assert themselves. Impulses which should be
disciplined become insurgent, and there is not a conflict but a stampede.
w The private,” says Dr. Head, “ develops a conversion hysteria and is
carried from the danger-zone paralysed. The officer becomes the
victim of an anxiety neurosis and commits suicide.” An army medical
officer, writing to the Times, says that “ well-bred horses, like well-bred
men, or shall we say highly organised men, suffer from shell-shock
more than low-bred ones, though the same well-bred horses are in¬
finitely more gallant than their low-bred companions.”

There is a well-known anecdote related of some great general who
read on a tombstone the inscription, “ Here lies one who never knew
fear,” and upon this remarked—“ Then that man can never have snuffed
a candle with his fingers.” The emotion of fear must have been felt
by all who in the war have been exposed to imminent peril to life and
limb, and who have at the same time seen around them wounds, death
and boundless anguish and misery, but in the well-balanced mind the
counteractives have been sufficient to hold the emotion in check. The
terrified soldier, we have been told, is restrained by the thought that if
he runs away he will be shot at dawn, but that is a crude explanation
of the way in which terror has been resisted. The instinct of self-
preservation is assuredly primary and paramount, but even in the lower
animals it may be set aside by love of offspring or a rudimentary sense
of herd obligation, and in man it is subordinate to a multiplicity of
sentiments and ideas, ingrained or fluent, which hold up the hands of
the will to resist its promptings, however insistent these may be.
Martyrology is a chronicle of the triumph of religion over the self¬
saving instinct and heroism is invariably associated with its abnegation.
Even inexcusable superstition is sustaining against it. “ A man has a
mascot,” writes home The Boy with the Guns, “ a charm of little worth
though of great value to him, or a photograph or flower; he loses it
and then loses his life. Such things are always happening. And the
men must have something to believe in, and something tangible to
express their belief—a sign, a symbol, something, a link between them¬
selves and the inexpressible, between themselves and all that they
cannot see or understand but which they feel exists.” But the degree
in which the instinct of self-preservation may be held in check under
terrifying conditions depends on the functional activity for the time
being of the highest cortical centres in the brain. Where these are
vigorous and have been braced by discipline a man can command
himself and retain self-possession throughout the most appalling ordeal,
but where they have been weakened and worn down by long stress, by
the constant expectation of evil, or by bodily debility the bravest may
respond to fear-inspiring impressions with reflex uncontrollability.
Under such circumstances self-preservation may assert itself as

LXVI.

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216 THE FIRST MAUDSLEY LECTURE, [July*

inevitably as the blinking of the eye on a threatened blow. Re¬
membering what our men went through, it is reassuring to know that
in cases of cowardice and desertion no man was condemned to death
who could justifiably plead shell-shock or some mental damage. When
a soldier, in bis defence or in mitigation of punishment, urged a sub¬
stantial plea on mental grounds, medical witnesses were called, and the
court-martial was adjourned and a medical board was held. At the
adjourned hearing one or more members of the board were called as
witnesses, and amongst them was always a mental specialist if there
was a suggestion of shell-shock or other kind of mental or nervous
disorder.

The fear factor, as disclosed in many of the war psychoses, has been
simple enough in its operation. A man became possessed by fear, felt
ashamed of it, struggled against it, and concealed it from his com¬
panions, but it gradually increased in stringency as he suffered more
and more from fatigue and hardship, and finally overcame him, ending
in a fit followed by mental confusion and delusions. For practical
purposes is it necessary to proceed further in such a case or to invoke
psycho-analysis ? That the mental breakdown resulted from fear, which
a sense of duty and self-respect and apprehension of ulterior risk were
unable to subdue, is obvious enough. Shall we be much wiser or
better able to help our patient if we trace it back, or pretend to trace
it back, to an unresolved infantile mode of behaviour or to some rela¬
tion between it and unsatisfied sexuality? The conclusion that the
morbid variety of fear represents the discharge of repressed and uncon¬
scious sexual hunger is, we have been told, one of the most securely
established in the whole range of psycho-pathology, upon which my
comment would be—“ So much the worse for psycho-pathology! ”

Emotional conditions, especially when violent and often repeated,
are extremely potent in precipitating new mental arrangements, and it
is little wonder, therefore, that the profound agitations which our men at
the front have passed through have resulted in disruptions of mental
continuity corresponding with disruptions of physiological continuity
in the brain. “ One thing we may conclude certainly,” said Maudsley;
"of all moral commotions and mental overstrains which cause insanity—
that they do so by straining or breaking the molecular ties of nerve
structure and so injuring or destroying its vital activities.” ProE
Waller’s recent experiments, following on the lines already laid down
by F£r£, Tarchanoff, Slicker, Muller, and Peterson, have proved
that large and sudden electric discharges which are independent
of any muscular movement accompany a great many of the
alarms and shocks of life. It was found that when strong and dis¬
agreeable stimuli were used—such as an unexpected loud sound,
an unexpected burn, a disagreeable and pungent smell, or a

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1920.] BY SIR JAMES CRICHTON-BROWN E, D.SC.

painful thought—while muscular movement of any kind was absent,
marked electrical actions occurred. In a Belgian woman who was told
to think of her native land—she had seen various tragic episodes of
the German occupation—a very strong reaction was evidenced, and it
was always noticed that the most effective ideas were such as were
accompanied by disagreeable or painful emotion. We are, I think,
justified in inferring that it is in such electrical discharges accompanying
the intense and violent emotions evoked by the war that we have the
explanation of many of those sudden losses of function which have so
often followed these emotions. Impinging on the synapses of the
neurons, which play so important a part in psychical processes, and
which are the weak points in the nervous pathways, it may well be that
they have increased their resistance in certain areas to the point of non-
-conductively producing a state analogous to fatigue which, when
excessive, results in changes in the cell substance. The discharges
would be most damaging in the higher and later developed levels of
the nervous system, where the cells’ functions are less solidly organised
than in the lower levels, where they are relatively firm and open to the
nervous currents, and they would be most likely to induce injurious
effects where the neurons are constitutionally less closely compacted
and more unstable. An apt illustrative analogy of what probably takes
place under such circumstances is supplied by Mr. Charles Salmonds.
41 We may picture,” he says, “an electric current passing through a
copper rod divided into a large number of segments ; if at one end of
the rod the segments are pressed firmly together the current passes
easily; if at the other the segments barely touch one another the
current passes the junctions only with difficulty.” Prof. Waller
observed that different subjects react very differently to different
stimuli, and the same subject in different states of health and at
different hours of the day to identical stimulation; and so we can
understand how the violent emotions of the war have caused sudden
brain blockage in men predisposed to hysteria, neurasthenia, or the
psycho-neuroses, exhausted by strain and stress or worn down by
illness, while they have left men of more equable temperament and in
sound health unscathed.

Recovery from brain blockage and the re-establishment of synaptic
transmission sometimes takes place almost immediately, and, as it were,
spontaneously; sometimes gradually, in altered environment and under
medical treatment or re-education, and sometimes even after long delay
quite suddenly under an emotional jerk much milder than the original
shock, but, like it, accompanied, no doubt, by an electric discharge,
exciting a change in the synaptic membrane by which transfer takes
place. The emotions producing brain-blockage are almost invariably
of a painful and startling description ; those removing it are generally

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218 the first maudsley lecture, [Julyv

of a pleasurable complexion. We are all familar with such cases.
Many disabilities have been swept away in the twinkling of an eye by the
announcement that a man would have no more fighting to do. Power
was instantly restored to the paralysed arm of a soldier on receiving an
affectionate letter from his wife. A soldier who had been rendered
deaf and dumb during the fighting in Flanders regained speech and
hearing in a burst of laughter during a humorous sketch at a concert
in his hospital, and another soldier struck dumb in battle was cured on
the spot by being kissed by a young lady visiting at his bedside. The
way in which an emotion may counteract the effect of mental shock
and blockage is very beautifully illustrated by Tennyson:

" Home they brought her warrior dead;

She nor swooned nor uttered cry;

All her maidens watching said,

' She must weep or she will die.’

“ Then they praised him soft and low.

Called him worthy to be loved,

Truest friend and noblest foe.

Yet she neither spoke nor moved.

“ Stole a maiden from her place,

Lightly to the warrior stept,

Took a face cloth from his face;

Yet she neither moved nor wept.

" Rose a nurse of ninety years,

Set his child upon her knee.

Like summer tempest came her tears.

‘ Sweet my child I live for thee.’ ”

The appropriate affinitive impression for the relief of shock in this
case—an excitation that discharged inhibition—was discovered, not by
any process of psycho-analysis, but by the ripe experience of an old
woman. Similar experiences sometimes surprise us in our asylums. I
remember reporting the case of a young woman (S. W—) who had been-
a schoolmistress and who laboured under dementia prsecox—or acute
dementia as we then called it. She was depressed, imagining she had
done some great wrong, and markedly stereotypic, remaining fixedly in
any position in which she was placed, and being generally mute. She
was several months under treatment, showing no marked improvement,,
when suddenly one evening she shook off her lethargy and became
quite herself, and remained from that moment bright, intelligent and
natural in her conduct. Her quick recovery she herself explained,,
saying that it came about as she was being fed with her evening meal
by a new nurse who had just come into the ward. She heard the
nurse tell another nurse that she came from Lincoln, and the mere
mention of Lincoln, where she had herself been born and reared

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219

>920.] BY SIR JAMES CRICHTON-BROWNE, D.SC.

-called up a flood of happy memories which swept her delusions and
inertia away. The motherland suggestion, as the psycho-analysts
would call it, was obviously the touchstone in this case, but perhaps
the course of baths and tonics to which the patient had been submitted
had prepared the way for its magical effect.

We have all, no doubt, met with instances of this sort in which there
has been sudden relief from brain stasis by an emotional antigen, and
most of us must have had personal experience of the effect of a summation
of voluntary stimuli in procuring significant brain changes at an express
rate. In the lapses of memory which occur during fatigue, illness or
old age, we grope anxiously about for a time for a proper name, and
then it suddenly flashes upon us, the reinforced mind current having
spanned the synaptic gap, just as an electric current of higher poten¬
tiality will spark across an interval that was too wide for a current of
lower potential to leap.

In connection with sleep sudden brain changes are noticeable. Its
incursion is ordinarily gradual. The senses are closed, will-power is
let slip, and fancy, free from control, sports for a little discursively and
then subsides; but sometimes, as in extreme fatigue, sleep comes
instantaneously with a snap. There is, as it were, brain stasis in sleep
but no general blockage, and on waking the stasis gradually gives way
before the stream of returning consciousness, first trickling and then
flowing freely; but the stream may come with a gush, and then in¬
stantaneous awaking occurs. Dreams are, of course, replete with
sudden variations, and Dr. Hughlings Jackson suggested that certain
absurd and persistent delusions are fixations of grotesque fancies and
dreams in which a morbid change in the brain has happened suddenly
and increased suddenly during sleep. The fixation of the grotesque
fancies or ideas gives rise to an imperative and fixed idea, and
Hughlings Jackson thus accounted for these quasi-parasitic states or
delusions in cases where general mental power is but little lessened.

Deeply interesting studies of sudden brain changes may be made in
-connection with what is known in religion as conversion, of which I
must only speak here with great deference and reserve. On its theological
aspects I must not touch beyond saying that it is by great multitudes
of people regarded as a direct spiritual influx and outpouring of divine
grace—a sort of celestial telepathy—and there can be no doubt that it
has, on the large scale, meant an altered attitude towards life and a
favourable change in disposition, character and conduct, sometimes
transitory but often enduring. But from the physiological side it is an
inner brain happening with new arrangements of nerve-currents, and
where it has taken place in connection with revivals it has often pre¬
sented many of the features of recovery from shell-shock and anxiety
neuroses, and under such circumstances might be described as soul-

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220

THE FIRST MAUDSLEV LECTURE,

[July,

shock. It is no slow growth, but catastrophic in character. John.
Wesley said: “In London I found 652 members of our Society wha
were exceedingly clear in their experience and whose testimony I had
no reason to doubt. And every one of these, without a single exception,
has declared that his deliverance from sin was instantaneous—that the-
change was wrought in a moment.” In the revival cases certainly, and
in many others just as in our psycho-neuroses cases, the soul-shock has
been brought on by fear, or by fear and the promptings of the instinct
of eternal self-preservation. It has been by appeals to fear that revivalists
have carried out their mission. They have succeeded in inducing in
their more sensitive auditors a state of terror not unlike that experienced
by the more emotional of our soldiers in the perils of the trenches and
the field. Our men have constantly described the battles in which
they took part as “ hell,” and it is by visions of hell conjured up before
them that the ardent votaries of evangelical religion have been plunged
in emotional perturbation. Jonathan Edwards, whom all succeeding
revivalists have imitated, thus horrifically played on the feelings of a
congregation : “ If we should suppose that a person saw himself hanging
over a great pit full of fierce and glowing flames by a thread that he
knew to be very weak, and knew that multitudes who had been in that
position before had fallen and perished, what distress would he be in.
The unconverted belong to the devil, and he is ready to seize them the
moment God permits. God is more angry with many of you now than
he is with many in the flames of hell. Some of you will within a year re¬
member this discourse in hell. You would have gone to hell last night had
not God held you like a loathsome spider over the flames by a thread.”

We cannot be surprised that exhortations like this, delivered with
superlative earnestness and unction, repeated again and again, wrought
up to great excitement a crowd of people often in a state of exhaustion,
for the services went on for hours, sometimes continuously by day and
night. Shouting, singing and groaning were indulged in, and all sorts
of nervous disturbances and even insanity resulted. Let me quote a
description of a revival at Red River in 1800. At the words of an
effective preacher faces were streaming with tears at a pungent sense of
sin, and the cries for mercy were terrible to hear. The floors were
covered with the slain. Services were held for seven days and some¬
times all night. The circulation was affected, and nerves gave way ;
many dropped to the ground, cold and still, or with convulsive twitches
or chronic contortions of face and limbs, and at Cover Ridge 3,000
were laid out in rows. The crowd swarmed all night from preacher to
preacher, singing, shouting “ Lost! Lost! ” leaping and bounding
about. As the excitement went on it took the form of jerking,
beginning with the head; with others it became barking, or the holy-
laugh, as it was called. They saw visions and dreamed dreams.

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1920.] BY SIR JAMES CRICHTON-BROWNE, D.SC.

The transports of these revivalists were, for the most part, short-lived,
and passed away, leaving only nervous exhaustion behind, but in a
large number of instances they were followed by anxiety neuroses and
psycho-neuroses' of a pronounced type. There was prolonged melan¬
cholia, with delusions, headaches, sleeplessness, hallucinations—such
as voices summoning to repentance and visions of the Day of Judgment
—palpitations, sweatings, indigestion, vomiting, and nervous tremors
and convulsions, and it was from this state of engrossment of the mind
by one system of ideas that conversion was the escape. By persuasions
by the minister or evangelist, by suggestions of friends, by some
emotional appeal in the singing of a hymn, or by some trivial and
apparently irrelevant incidents, as the reading of a text, conversion
came in a flash, and not only was mental tranquillity restored, but a
state of complete happiness was reached. A transformation took place
which could not be clearly set forth in words, but which was vaguely
described by those who had undergone it as “ Heaven upon earth,”
“a mighty presence," “a sense of newness,” “a great surrender,”
“ assurance of salvation,” “ a glorious light,” “a wave of the spirit,” and
so on. In such cases the translation from one order of thought and
feeling to another that occurs in so many young people brought up in
evangelical circles, as a normal phase of adolescence and a growth into
a larger spiritual life, takes place momentarily. At the summons of
some particular event or word a feeling is aroused that spreads itself
like wild-fire over the whole field of consciousness and imparts a
colouring to all elements included in it. This religiosity per saltern
connotes a sudden change of current in the association centres of the
brain. The old system is changed, beaten tracks are deserted, and new
communications are opened up. In a violently excited state of emotion
pressure in the brain-cell or psycho-active matter is increased just as a
stronger current is yielded by a heated electric cell. And this gives
rise to movement without and within. There is muscular restlessness,
associations are no longer regulated by established canons, overflow
takes place, and after an inundation, more or less wide-spread—the
confused and hallucination period—fresh channels are hollowed out
and an entirely new system of canalisation is established. This may be
permanently maintained, or it may be relinquished, in a return to the
old system.

The Eleusinian mysteries seem to have had something in common
with modern revivals. They aimed at counteracting the passions of
ordinary life by the abiding remembrance of an appeal to terror and
pathos, and so profound was their influence that it was said of some
who have gone through them that they were never seen to smile
afterwards.

Many who have never undergone religious conviction are aware of

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222 THE FIRST MAUDSLEY LECTURE, [July,

secular experiences of a somewhat similar type, critical moments in
their lives—often during adolescence—when quite suddenly and without
warning new life streamed in on them, as if from without A course
of study may have led up to it, a strong emotion may have pre¬
ceded it, or some quite trifling incident may have determined it, but
abruptly and inexplicably the change came, and a sense of strange¬
ness and expansion dawned. There was a jolt, a turn, and the mental
contents were as if kaleidoscopically re-arranged in an order different
from that which had hitherto obtained. A memorable example of this
spiritual new-birth, reached not by gestation but by a regenerative
flash, as it occurred to Carlyle he has himself described: “ Nothing,” he
wrote, “ in Sartor Resartus , is fact, symbolical all, except that of the
incident in the Rue St. Thomas de L’Enfer, which occurred quite
literally to myself in Leith Walk. The incident was as I went
down I could now go straight to the place,” and the incident may
be epitomised as follows: “ Full of such humour and perhaps the
most miserable man in the whole French capital or suburbs
was I one sultry Dog-day after much perambulation toiling along
the dirty little Rue St. Thomas de L’Enfer, when all at once there
arose a thought in me, and I asked myself 1 What art thou
afraid of?’ and as I so thought there rushed like a stream of
fire over my whole soul, and I shook base fear away from me for
ever. I was strong, of unknown strength; a spirit, almost a god.
From that great moment of Baphometic Fire baptism I became a
new man,” or, as Carlyle has it, “ I authentically took the devil by the
nose ”—a victorious ending of a protracted conflict

But besides sudden expansions there are sudden contractions of
brain energy. “ The memory of James Hinton as a boy,” Sir William
Gull has said, “was quite marvellous. A school-fellow of his at
Reading recalls that when the master set six pages of history, Hinton
read it once over and repeated it verbatim. But rushing one day
hurriedly from cricket to his lessons there was a sudden lapse of this
remarkable power, a sense of gone-ness, and it never returned to him.”

I have referred to cases in which sudden recovery from insanity has
taken place, in response to some moving emotion, and we are all
familiar with cases in which sudden recovery and relapse occur under
some periodic physiological law still unexplained, allotropic brain
changes they might be called. But I should like to mention that there are
cases in which sudden recovery supervenes on a physical concussion
or jar. It is easy to understand why physical shock should interrupt
the functions of the brain, but it is not so easy to understand how it
should resuscitate them and restore their balance. Some time ago I
visited a gentleman who bad for years laboured under delusions of
persecution, which had become so aggressive as to make him dangerous

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1920.] BY SIR JAMES CRICHTON-BROWNE, D.SO.

and to necessitate bis being placed in an asylum. Two attendants
having arrived at his house to remove him, he rushed upstairs to
escape from them, and jumped from a first-floor window into the street.
When he was picked up it was found that his vertebral column was
broken in the dorsal region, but that he was perfectly clear in mind.
His delusions had vanished, and he was reasonable and collected. He
ultimately died from the effects of his injuries, but he lived some
months, and was lucid to the end. The late Dr. Robert Smith, of the
Durham County Asylum, reported a similar case, that of a woman,
set. 36, labouring under confirmed melancholia, who one day, under
the hallucination that she saw her husband outside, smashed a window-
frame with a brush-handle and jumped through, falling a height of
24 ft. and alighting on a gravel walk. She fractured her leg and
sustained other injuries, but did not lose consciousness, and recovered
her soundness of mind on the spot. All her depressed delusions left her,
and, in the course of a few weeks, she went home quite well. Sir James
Dundas Grant has given me the notes of the case of a man who was
wounded at Delville Wood on the Somme in July, 1916, by a bit of an
exploding shell. He remembered nothing more until, coming to him¬
self in a train, he found he could hear nothing. He remained deaf until
August, 1917, when one night he had a vivid dream that he was going
through the shell incident again. In the agitation caused by this dream
he fell out of bed and knocked his head on the floor. His mother
hearing the noise, came into the room and asked him what was the
matter. He heard her question and replied, and has been able to hear
perfectly ever since.

One can only speculate as to what went on in the brain in such
cases, but assuming that it was not a psychical shock that proved
curative, it might be suggested that the change was analogous to the
rearrangement of particles and altered electric resistance that takes
place in a coherer when it is tapped. The impact broke down morbid
cohesions in brain elements, permitting unusual conditions, and then
the nerve currents flowed back into their normal channels.

Dr. Feldman has described the case of a woman suffering from
trinitrotoluene poisoning, who illustrated the effects of physical shock
during suspended brain function. She developed delirium quite
suddenly, was restless, and not in her right mind, and then developed
twitchings and became semi-conscious, the jaundice being intense.
The window just over her bed in the Poplar Hospital was broken by
the great explosion in January, 1916, and she sustained a severe shock,
and the remarkable feature of the case was that by the next morning
she had completely recovered consciousness and was quite natural.
On the second day she was much improved, but on the fourth day she
had relapsed into the same condition she was in before the explosion.

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2 24 THE FIRST MAUDSLEY LECTURE, [July,

A severe physical shock had, in this case, a very marked effect on the
central nervous system, even during what proved fatal toxaemia.

In recurrent insanity we have, one may suppose, alternating currents,
the brain, in which resistance in the synapses in certain tracts and
centres normally in relation is for a period increased to the point of
blockage, and is then, for another period, relaxed and overcome, and
the alternations often take place quite suddenly. Some years ago I
visited, with the late Dr. Louis Bockhardt, of Manchester, a lady who
suffered from intermittent mania. On one day she was in all respects
lucid, calm, rational, intelligent; on the other she was a different being,
excited, incoherent, mischievous. This sad sequence had gone on for
years when, on one occasion, it was curiously interrupted. The lady,
being a German, attached much importance to the domestic observance
of Christmas, and Christmas Eve, being her good day, she spent happily
with her family. On returning with her nurse to her rooms in the
evening she said to Dr. Bockhardt, “ I mean to eat my Christmas
dinner with my mother at her house to-morrow.” “That is not
possible,” Dr. Bockhardt replied, “for to-morrow is your bad day.”
“ Yes,” she said, " but I will tell you how I can manage it. I will make
to-day and to-morrow into one day. I shall keep awake all to-night,
and I shall be as well as I am now to-morrow morning.” She kept her
word. She went to bed, remained there quietly the usual time, wide
awake, the nurse sitting up with her, and was calm and collected on
Christmas morning and dined with her mother on that day. She slept
well on Christmas night and awoke the following morning in the state
of mental excitement which had been postponed for twenty-four hours.
In this case the change in the couplings of the nerve centres corre¬
sponding with orderly and disorderly mental action only took place
during the suspension of the influence exerted by the higher nerve
centres over the lower which takes place in sleep, and the patient,
having herself become aware of this, was able by maintaining the
activity of the higher centres to put off for a time the running riot of
the lower ones. She gave an extension of power to inhibition, but she
could not permanently re-establish its authority.

In a moment of bitterness Maudsley once imagined a physician who
had spent his life in ministering to the mind diseased looking back sadly
on his track, recognising the fact that one-half of the diseased beings
he had treated had never got well, and questioning whether he had
done real service to his kind in restoring the other half to reproductive
work. But it was in no such mood that he provided for the Maudsley
Lectureship and Hospital. He must, then, have had faith in the seeds
of time and hope in the future of psychological medicine, and it is, I
feel sure, in such faith and hope that our speciality accepts his gifts and
pursues its mission. The old order changeth everywhere, and the new

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22 $

1920 .] BY SIR JAMES CRICHTON-BROWNE, D.SC.

order that is taking its place, in our department at any rate, however
diverse its methods may be, is alive and in earnest. There is no help¬
less folding of the hands, nor shruggings of despair, but strenuous
endeavour and a confident expectation that much may and will be
done to stem the devastating tide of madness and to increase the
number of rescues from its troubled waters.

Proceedings.

The President said it had fallen to his lot to have the honour of presiding at
the First Maudsley Lecture. He thought that any of his hearers who contemplated
the problems of history would always find it difficult to judge whether any special
event, or any particular individual, had had much influence in shaping history.
But in this particular case he thought they would have very little doubt. In the
years immediately following the publication of The Origin of Species there
was a great awakening on the subject of the study of psychological medicine, and
in this regard two names stood out. One of those was the name of Dr. Maudsley,
whom they were now met to honour, and the other was the name of the Lecturer
to-day. (Hear, hear.) He did not intend to speak about Dr. Maudsley at all: that
was the subject of the Lecture. He wished merely to say, in that regard, that this
Lecture was due to his munificence in bequeathing a sum of money for lectures
on the subject of mental disorders and allied sciences. Maudsley's life was
devoted to the welfare of the insane: posterity was to be benefited by his foresight.
In the early years of the West Riding Asylum, 1871 and onwards, under the care of
the then Dr. Crichton-Browne, there was a galaxy of talent which had an immense
influence upon history. Among the early contributors were David Ferrier,
Herbert Major, T. W. MacDowall, Hughlings Jackson, Clifford Allbutt, W. B.
Carpenter, Lauder Brunton, John Merson; and this was all organised and
arranged by Sir James Crichton-Browne, who was to lecture to this audience
to-day. He thought the connection between that and Dr. Maudsley’s first book.
Physiology and Pathology of Mind , which was published in 1867, was in¬
teresting. He was sure those two events had much to do with the development
of the specialty. He had great pleasure in asking Sir James Crichton-Browne
to deliver his address.

Sir James Crichton-Browne was cordially received and delivered his lecture
with an eloquence which always distinguishes his public utterances. His lecture
was heard with deep interest and many of his striking passages with much
applause.

On its conclusion, the President said the Lecture had been a wonderful one ;
beautiful thoughts had been expressed in beautiful language, and in a beautiful
way. And though they knew there could be no merit in eloquence as such, that
there was nothing more than temporary value in a silvery tongue, yet they did
know that when this was coupled with penetrating insight and with clear and lucid
thinking the result was wonderful, and such it had been to-day. He had been
particularly charmed by the note of hopefulness which ran through the Lecture.
He believed Sir James Crichton-Browne began the practice of medicine so long
ago as 1861, and he was President of this Association more than forty years ago.
He had now given a risumt of his work and of his thought, which was full of
hopefulness to those in the specialty; it was an inspiration to them, and he was
sure the audience would wish that Sir James should be cordially thanked for his
Lecture. (Applause.) He had one suggestion to make. He believed it was one
of the conditions attaching to the Lecture that it should be published in the Journal
of Mental Science. That, he did not doubt, would be fulfilled, and in that way it
would appeal to a very much larger number than could be present to hear it. As this
was not now a meeting of the Association, nothing in the way of business could
be done, but he proposed to suggest to the Editors of the Journal that the type
be kept up until there had been an opportunity for the Council of the Association
to come to a decision on that matter. He would like the Lecture to be printed
and circulated in pamphlet form, printed on good paper, and circulated widely, so-
that it would reach a much larger circle than the Journal catered for. He had

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the support of the Treasurer and the General Secretary in making the suggestion,
and he hoped it would be carried through. In order to give support to the thanks
he had ventured to express, he asked Sir George Savage to say a few words.

Sir George Savage said the duty which fell to him was a very simple one.
All who had heard the lecture must have appreciated it from beginning to end,
both its matter and the manner of its delivery. The orator who had to speak on
such a subject should refer to the man, to his works, and how he was represented
by his writings, and, most importantly, the way in which he would look upon the
work of to-day. Sir James Crichton-Browne, like the speaker, knew Maudsley for
many years, and they recognised his very strong individuality. He was a member
of the Reform Club, and he himself had many reforming characteristics. The
requirement of him (Sir George), however, on this occasion was not to speak of
Maudsley, but to express the feelings of gratitude entertained by this meeting
towards Sir James Crichton-Browne for having placed so lucidly before his
audience the character of the man and his works. He did not think there was any
man better calculated or more suited to give this oration than Sir James ; it was
the eloquent man discussing the fluent man. Maudsley was not the fluent orator
that Sir James was, but he was polished in his written word, just as Sir James was
polished in speech. He (Sir George) could not help wondering, towards the close
of the lecture, what Maudsley’s feelings would have been in regard to psycho¬
analysis, with what scepticism he would have approached that and the subject of
shell-shock. There was nothing so useful to mankind as prudent unbelief. He
was sure all present would feel that Sir James Crichton-Browne had inaugurated
this oration in a way which was worthy of him.

The vote was carried by acclamation.

Sir James Crichton-Browne (in reply) thanked the President and Sir George
Savage for their kind words. He regarded it as a very honourable compliment,
the greatest that had fallen to his lot, to be asked to deliver this lecture to his
friends and compeers in that department of medicine with which he (the speaker)
had been so long connected. And it was very gratifying to have an old friend like
Dr. Bedford Pierce in the chair, because he stood half-way between the old guard to
which he himself belonged and the new army which had sprung up and was now so
vigorous. Dr. Pierce had shown the wisdom and moderation of the old guard and the
originality and enthusiasm of the younger men who were pressing to the front.
There were some stipulations connected with the lecturer, and one which should
have been imposed in his case was that he should have been compelled to undergo
a course of instruction for the Diploma in Psychological Medicine before being
called upon to deliver. He would then have been better able to adapt himself to
the attitude of younger men with high philosophical and scientific attainments.
He had written the lecture under pressure due to other engagements, but he had
done it con amore, and his pen had run away with him; hence he had, in the
reading, left out page after page, with the feeling which occurs to all who
have to cut down their own compositions, that he was throwing perhaps
the best of his progeny to the wolves. And those excisions might have been more
painful to his audience than to himself, for they probably interfered with the con-
•secutiveness of the address. But he wished to express his great gratitude for the
patience with which he had been listened to. (Applause.)

Appreciation by the * Times,' May 2 is/, 1920.

Sir James Crichton-Browne, the distinguished alienist, called attention yesterday
to the “ load of lunacy ” under which the nation suffers. We are not sure that
the figures of lunacy, grave as they are, need be taken to indicate an increase in
insanity. There is an idol of the statistician as well as of the market-place;
increase and decrease of percentages require scrutiny before they should arouse
satisfaction or dismay. With insanity, as with other human afflictions, increased
skill in diagnosis, more thorough sifting of the population and the provision of
facilities for treatment discover cases that formerly passed unnoticed. Even at
present the school attendance officer unearths the idiot child, and the fool of the
family is handed over to the county asylum. We may predict with assurance that
when more psychiatric clinics are provided, the provision for out-patient treatment
extended and the legal formalities connected with certification are reformed, the
first result will be an apparent increase in the numbers of the insane. The process

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of prevention will reveal the extent of the evil. Everyone will agree on the need
of more facilities for the study and treatment of insanity. But alteration of the
law regulating the certification of lunatics is sure to arouse suspicion. The
putting away of an inconvenient relative by means of a certificate has been a
favourite theme of playwrights and novelists, and an occasional case in the Law
Courts seems to justify popular dread. Yet there is a strong case for alteration.
The existing Lunacy Act protects the liberty of the subject, but does not provide
sufficient scope for treatment and cure. The early symptoms of mental disorder
often occur before certification is possible. It is during these incipient stages that
skilled attention is most successful and most difficult to obtain. The Professor of
Psychiatry in the University of Edinburgh recently stated in our columns that
Scotland in this respect is more happily placed than England. For more than
fifty years mentally-deranged persons in Scotland have been able to receive
curative treatment in any house or home without being certified to be insane and
without being sent to an asylum. These powers have not been abused, and there
is no reason to suspect that they would be abused in England. At the present
time, indeed, insane patients are often sent by physicians from England to Scotland
to benefit by the more considerate laws. The army authorities during the war
arranged that mentally-disordered soldiers should be received into military mental
hospitals without orders or certificates, and did not send cases to asylums until
mental disability had lasted for nine months and was deemed incurable. Large
numbers of men were received in early stages of mental disease and were cured.
Authority and practical experience combine to recommend the reform of the
Lunacy Law.

The Relation of Infections to Mental Disorders .(*) By W. Fori>

Robertson, M.D.(Edin.).

Some of you may remember that, four years ago, I inflicted upon you
a paper dealing with almost the same question. It was entitled “ Some
Examples of Neurotoxic Bacterial Action.” Since that time I have
continued, in the Laboratory of the Scottish asylums, the practical
study of bacterial infections on a fairly wide basis, and I believe it is
now possible to define with something approaching exactness the part
which such infections play in the causation of mental disorders, including
insanity. It can now be shown that this part is a very much larger one
than at present is generally believed. The same can, however, be said
with equal truth regarding the relation of infections to common maladies.

It is to be remarked, in the first place, that asylum patients, like other
persons, may suffer from acute and chronic infections which produce
the ordinary results. For example, they are subject to common colds,
influenza, pneumonia, bronchitis, dysentery, and tuberculosis, all of
which are of bacterial origin. There is now, however, solid ground
for the conclusion that bacterial infections have also a special relation
to mental disorders. Nevertheless, there are few bacteria, if indeed
there are any, that can be said to produce insanity as the characteristic
result of their pathogenic action. The special relation is dependent
essentially upon a peculiar vulnerability of the central nervous system

(') A paper read at a meeting of the Scottish Division of the Medico-Psycho¬
logical Association, November aist, 1919.

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in some persons. This, I believe, is a conclusion that must be accepted
by anyone who considers the ascertained facts regarding the incidence
of bacterial infection in the insane and in the general population, and
the effect of properly directed therapeutic immunisation in both. It is
a view that has been expressed before, and never, in my opinion, better
than it was by Dr. C. C. Easterbrook (*) in the course of the discussion
on the psychoses of infection and auto-intoxication at the International
Congress of Medicine in 1913. Dr. Easterbrook asked, “ Why did only
a small proportion of feverish patients become delirious? Why did
only a very small proportion of subjects become mentally affected after
an attack of fever? Undoubtedly it was the nervous constitution,
temperament, disposition, or mental make-up of the patient that made
all the difference.” In his opinion, “ This was the common underlying
factor in the aetiology of insanity, and explained why only a relatively
small proportion of humanity broke down mentally under the action of
the many traumata or stresses that daily affect mankind, including the
infections and toxaemias. No one became insane without previously
being or becoming neurotic, and the neurotic constitution was mani¬
fested in many ways and from various sources of evidence, and especially
from the disposition, which perhaps it would be possible to express some
day in bio-chemical terms, and so to demonstrate that the neurotic with
abnormal chemical affinity of his neurons became a prey to infections
and toxaemias.” With every word of this pronouncement I agree. If
this position is accepted it is evident that, in order to advance our
knowledge of the pathology and treatment of insanity, we must investi¬
gate not only the exciting causes, but also the predisposing ones.
Neither of these two factors is simple—each is, indeed, extremely com¬
plex. There are many exciting causes apart from bacterial toxic action,
and the predisposing causes are still in many respects obscure and
-capable of only imperfect analysis. One very important distinction can,
however, be made between what we are obliged already to regard as
the chief component elements of the predisposing and exciting factors
respectively. It is that while we can do little or nothing to alter the
inherent qualities of the brain, which are largely fixed by heredity, we
can exercise now a very powerful corrective influence upon many of the
•common toxic conditions that excite mental disorder. Extensive investi¬
gation in the laboratory has shown that most of these toxic conditions
are bacterial in origin. The invading bacteria can be isolated, and
their injurious action is, to an important extent, capable of being con¬
trolled by therapeutic immunisation. Hence the subject of bacterial
infection has become one of paramount importance in the pathology of
insanity, just as it is now one of paramount importance in the pathology
of common maladies. Evidence of what I attest can be adduced, and
I hope soon to publish it in a systematic and detailed form in a book

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1920.]

on therapeutic immunisation. It is possible to give here only a brief
summary. Before I come to this, however, I must endeavour to make
clear one or two important points that it seems to me must be grasped
by anyone who would understand aright the relation of infections to
mental disorders.

It should be evident that there is a fundamental difference between
the manner in which toxins cause disorder of the mental functions in,
for example, acute confusional insanity and dementia praecox during its
later stages. The text-books, with one or two exceptions, do not explain
this difference. Their general point of view is that of pure psychology,
and on purely psychological grounds the matter does not permit of a
satisfactory explanation. It can be understood only when the pathology
of insanity is considered from a different standpoint altogether, namely,
that of general pathology. In an article in Green’s Encyclopedia and
Dictionary of Medicine and Surgery, I have endeavoured to show that
the pathology of insanity can be brought into line with general patho-
logy. To the orthodox psychologist this is impossible. The stumbling-
block is apparently the absurdity, in his opinion, of presuming to regard
mind as merely an expression of the functional activity of the brain,
corresponding to the functional activity of the stomach or kidneys. It
has been laid down by psychologists that “ Brain is not the organ of
mind in the sense in which it is the organ of sensori-motor activity,”
and that “ There is no evidence to support the position that mind is a
function of the nerve-fibres and nerve-cells.” On the contrary, it seems
to me that there is no definite evidence of its being anything else;
indeed, the view that mind is an expression of the functional activity of
the brain, or, more strictly, of the association centres, instead of being
absurd, is supported by a ma$s of anatomical, physiological, and patho¬
logical evidence that the psychologists are either unaware of or are
incapable of interpreting correctly. For my part I am certain of this,
that only by regarding the intellect and emotions as expressions of the
functional activity of the association centres can we ever obtain any
clear and useful view of the pathogenesis of insanity—clear, because it
defines and explains the mode of action of each pathogenetic factor,
and useful because it guides us to important therapeutic ends.

With the object of convincing you of the importance and necessity
of regarding in a particular way all toxic actions that have to do with
the causation of insanity, I must ask you to consider for a moment two
other interpretations of familiar facts. The one has regard to the asso¬
ciation centres as complex reflex mechanisms, and the other concerns
the nature of disease.

Every living thing is the product of two distinct factors—heredity
and environment. Heredity is only a moulding force, varying slightly
in its potentialities in different stocks in the same species. In co-

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operation with environmental forces, it builds up from the germ-cells,
a highly complex organism. The individual thus developed is a vital
reactive mechanism ; every vital phenomenon it is capable of exhibiting
is of the nature of a response to external stimuli. This is true of the
being as a whole, of the separate organs and of each cell composing
the tissues. For example, the functional activity of a glandular organ,
such as the stomach, is purely a response to stimuli from its environ¬
ment, which includes the other organs and tissues of the body. The
same principle applies to the nervous organs, and not only to the
lowest, but to the highest. The brain is a reactive mechanism of
extreme complexity, commonly elaborated to an extraordinary degree
by education. Consciousness we can understand only as a concomitant
of reaction in the associative or psychical centres. When we hear the
ring of the telephone bell and go to the instrument to answer the call,
we perform a series of complex reflex actions induced, firstly, by the
sound of the bell, and secondly, by the representations awakened thereby
in the psychical centres, and with every step of the series of reactions
there flows a stream of consciousness. Normal mental reactions are
strictly conditioned by the integrity of the central nervous mechanism.
If this mechanism is damaged its functional reactions must be abnormal.
The mechanism becomes damaged either by traumatism or as a con¬
sequence of disease. We have to consider the nature of disease.

Disease is essentially a reaction on the part of the living body to an
inimical force that has penetrated its first line of defence, constituted
by the skin and mucous membranes. Pathogenesis is an account of
the defensive struggle, of the forces engaged on either side, and of the
havoc often wrought in the course of the battle. As results of thi»
struggle and of the exposure of delicate structures to toxic actions,
irreparable injury may be sustained by various organs and tissues, in
consequence of which their functions are afterwards imperfectly per¬
formed and conditions of auto-intoxication are induced. Some tissues
have very little power of self-defence, and their escape from injury
depends upon their relative invulnerability. If a toxin is circulating
„ in the blood, it will fix itself in any substance with which it has a
chemical affinity. Now there are many toxins, and some of them of
bacterial origin, that have special affinities for nerve-cells. The liability
to be injured by such neurotoxins is, however, not the same in all
nerve-cells. There are wide local and individual differences, dependent
upon congenital and acquired qualities. Special vulnerability to toxins
on the part of the nerve-cells of the association centres in some stocks
appears clearly to be at least one important factor included in hereditary
predisposition to insanity. Two distinct effects upon the association
centres must be recognised. During the height of the toxic action the
metabolic processes occurring in these centres are seriously disturbed;

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1920.]

mental reactions correspondingly are disordered and consequently there
is confusion, excitement, depression or stupor. If the toxic action sub¬
sides there may be complete recovery on the part of the tissues, in which
case the mental reactions again become normal. In other cases there
is destruction of many neurons and irreparable injury to many more.
The centres are permanently damaged and the mental reactions there¬
fore remain more or less abnormal. Thus regarded, mental disorders
are abnormal reactions of an associative mechanism that is damaged by
active, or former disease, or by traumatism, or that is defective owing
to some developmental fault. We can now understand the fundamental
difference in the manner in which toxins cause disorder of the intel¬
lectual functions, respectively in acute confusional insanity and in
dementia prsecox during its later stages. In the first the toxic storm
still rages, perverting the metabolism of the nervous centres and there¬
fore also their delicate reactive qualities; in the second the toxic storm
has passed over, perhaps many years before, leaving a permanently
damaged nervous mechanism which can react only abnormally. The
brain of an insane person may be likened to a piano, the intricate
mechanism of which is broken, rusted or clogged; the player represents
the environment to which it can react Though his skill is perfect, by
6ngering the keys he can produce nothing but discord.

If we can regard morbid mental phenomena in this way, we must
recognise the enormous practical importance of the many inimical
forces that are capable of breaking through the first line of defence of
the body and damaging temporarily or permanently the delicate reactive
mechanism of the association centres. My present purpose is to con¬
sider only one group of such inimical forces, namely, pathogenic
bacteria and their toxins. I have already occupied too much of your
time, and I shall give merely a summary of the conclusions that the
evidence now seems to warrant. This evidence is derived from investi¬
gation of the infections in a long series of cases, from the study of focal
reactions, jrhich establish the fact of the pathogenic action of the
bacterium! and often reveal much regarding its special toxic properties,
and, lastly, Aom the observation of the effects of therapeutic immunisation.

As in common maladies the infections are generally complex, though
there is frequently a leading one. The most common seats of infection
are the mucous membranes of the respiratory, alimentary and genito¬
urinary tracts.

I will take first one of the minor forms of mental disorder, namely,
neurasthenia. In this extremely common malady there are always
phobias—pathological exaggerations of protective instincts; there is a
constant sense of fatigue, amounting in some cases to complete prostra¬
tion. The superficial reflexes are exaggerated. Volumes have been
written about it during the past three or four years, and the explanations

LXVI.

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MENTAL DISORDERS.

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advocated are, apart from the cases in which there has clearly been
physical injury to the brain, almost entirely of a psychological nature.
Shell-shock is really cerebral traumatism and should not be confused
with neurasthenia. The nervous disturbances following terrifying
experiences have also essentially a traumatic pathogenesis, and axe
capable of being regarded as purely the effect of psychical traumatism.
True neurasthenia commonly develops without any of these antecedents,
which, however, may precipitate or intensify it The true cause of
neurasthenia is chronic bacterial infection—exactly the factor that a
hundred authorities ignore. By far the most common infection is an
intestinal one by a neurotoxic micro-organism—an anaerobic diphtheroid
bacillus. I have investigated over ioo cases. Focal reactions and the
effects of therapeutic immunisation have amply established the relation
between this particular infection and the nervous symptoms. A minority
of cases is due to other chronic infections, especially by the bacillus of
influenza, aerobic diphtheroid bacilli and pneumococci.

I have said that there are no pathogenic bacteria that cause insanity
as their characteristic effect Whilst this is strictly true,* the statement
comes very near to being falsified by one sub-group. Much evidence
has now accumulated to show that some species of diphtheroid bacilli
are intensely neurotoxic. They are not nearly so common as the anaerobic
intestinal diphtheroids of which I have spoken. Infection by one of
these intensely neurotoxic diphtheroids is one of the commonest causes
of acute confusional insanity. In some cases of this kind there is what
may be termed diphtheroid saturation. Nearly all the mucous mem¬
branes are infected by the bacilli. These are being passed into the
blood-stream and poured through the kidneys into the urine. Some
cases of this kind of infection have served to demonstrate a fact of great
practical importance, namely, that psychical traumatism may increase
the vulnerability of the nerve-cells and so determine the onset of the
acute phase of the mental disorder. Other bacterial causes of acute
insanity are Streptococcus pyogenes , the bacillus of influenza and the
pneumococcus. }

The majority of the cases of insanity that I have had an opportunity
of studying have been such as would be classed among the affective
psychoses. In this group therapeutic immunisation has certainly a
wide and profitable field. I have now investigated many cases and
have in several carried out a course of therapeutic immunisation myself.
It may be said that suppression of existing chronic infections in these
cases is attended, as a rule, by recovery from the mental disorder.
The chronic infections found include those by various species of neuro¬
toxic diphtheroid bacilli, Streptococcus pyogenes , Streptococcus facalis
hcemolyticus , pneumococcus, Bacillus influenza , bacillus of Friedlander
the gonococcus, Bacillus coli communis and a few others.

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Cases of dementia prsecox in the active phase of the disease constantly
suffer from extremely severe bacterial infections of various kinds.
Neurotoxic diphtheroid bacilli are prominent in most; they are found
especially in the nasal passages and the genito-urinary and intestinal
tracts. Chronic intestinal infections by pneumococci are very common.
In several cases made the subject of a general bacteriological investi¬
gation and immunised with autogenous vaccines, the progress of the
malady appears to have been arrested.

I have no bacteriological data with regard to epilepsy, and I would
merely say that in the present position of knowledge investigations of
the intestinal flora by anaerobic as well as aerobic methods would
probably throw some light on the toxic factor that is undoubtedly
present in this malady.

In cases of senile insanity there are always severe chronic bacterial
infections. The most vulnerable tissues are those of the cerebral
arterial system, and chiefly, though not exclusively, through toxic injury
to this the association centres become involved.

Lastly, in dfementia paralytica a spirochaete infection of the brain has
been shown to be an essential factor. According to the orthodox view,
it is the exclusive cause of the disease. Bacterial infections are, however,
always added, and they are, I maintain, of equal importance in the
pathogenesis of the malady. Spirochaete infection alone of the brain
will produce only cerebral syphilis and not dementia paralytica. It is
certainly bacterial infection and not the spirochaetal one that kills the
patient

(*) Seventeenth International Congress of Medicine, London, 1913. Section XII,
Psychiatry; Pt. II, p. 128.

The Psycho-pathology of Alcoholism and Some So-called Alcoholic
Psychoses.Q) By C. Stanford Read, M.D., Physician to
Fisherton House, Salisbury.

The social problems connected with alcohol are always before us,
but social reconstruction after the great war has brought them into
greater prominence than ever, while America having gone “ dry ” and
the prohibition campaign starting in this country have brought
the question of alcohol home to even the unthinking section of the
community. In the past we have had the physiological effects of
alcohol put before us almost ad nauseam, and everyone is fully aware of
the disastrous wide-spread results of excessive drinking. Well-meaning
temperance reformers are continually pointing out the intimate relation-

(•) Read at the South-Western Branch of the Medico-Psychological Association,
Portsmouth, April 23rd, 1920.

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ship existing between alcoholic excess and illness, crime and pauperism.
Not so very long ago in the press, we had the almost amusing incident
of a manifesto issued by a list of eminent physicians, who decried its use
in medicine, followed not long afterwards by another manifesto signed
by an equally eminent catalogue of medical men, who laid much emphasis,
on the beneficial effects of alcohol as a therapeutic agent The personal
factor is always apt to colour one's views, and I may be no exception to-
the rule. It is a common fallacy to suppose that science is free from
bias and prejudice, but the facts I shall bring before your notice with
regard to the relation of alcohol to mental disease will tend to indicate
their presence.

Now in order to have an adequate grasp of any problem, it seems
evident that its study should be approached from every point of view,,
yet until recently the psychological aspect of alcohol has been left
mainly untouched. The purport of this paper is to dwell superficially
on the light that modem psychology has thrown upon the relation
existing between alcohol and the psychoses.

It seems feasible at the outset to presume that mankind all over the-
globe desires and indulges in fermented liquor for some deep-seated
reason. Yet we must, on analysis, come to the conclusion that man ration¬
alises freely on this point when he gives his so-called reasons for drinking,,
and that it is but seldom that the real impulse lies in his consciousness,
but that unconscious motivation is at work which in the main has as its
object the saving of individual mental pain. Trotter (*) on this point
says, (< Alcoholism almost universally regarded as either, on the one
hand, a sin or vice, or, on the other hand, as a disease, there can be
little doubt that in fact it is essentially a response to a psychological
necessity. In the tragic conflict between what he has been taught to
desire and what he is allowed to get man has found in alcohol, as he
has found in certain other drugs, a sinister but effective peace-maker, a
means of securing, for however short a time, some way out of the prison-
house of reality back to the Golden Age. There can be equally little
doubt that it is but a comparatively small proportion of the victims of
conflict who find a solace in alcohol. The prevalence of alcohol and
the punishments entailed by the use of the remedy cannot fail to impress,
upon us how great must be the number of those whose need was just
as great, but who were too ignorant, too cowardly, or perhaps too brave
to find a release there.”

One must lay stress, too, upon the effects alcohol has in promoting the
social instincts and in paralysing the repressing forces of social taboos.
The pleasure that emanates from its imbibition is by no means mainly
physiological in origin. It also is due largely to the narcotic effect
exerted on the higher mental processes, especially social and ethical
inhibitory, whereby those, which normally are controlled by these and.

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235

kept from consciousness through repression, are released. The mere
lessening of inhibition, by which means a man feels a greater freedom of
bis ego, brings a sense of elation.

In the face of this view-point, the question of prohibition takes on a
•different aspect Many of us are inclined to prophecy that total
prohibition would tend to cause an increase in varying types of neuroses
-and psychoses, and regret that instead of such a measure some means
were not scientifically advocated to remove where possible the under¬
lying defects that render alcohol a necessity, and an apparent menace to
society generally. Ferenczi (*) says, “The one-sided agitation of
temperance reformers tries to veil the fact that in the large majority of
instances alcoholism is not the cause of neuroses, but the result of them,
and a calamitous one. Both individual and social alcoholism can be
cured only by the help of psycho-analysis, which discloses the causes of
the ‘flight into narcosis’ and neutralises them. The eradication of
alcoholism only signifies an improvement in hygiene. When alcohol is
withdrawn, there remains at the disposal of the psyche numerous other
paths to the ‘ flight into disease.’ And when, then, psycho-neurotics suffer
from anxiety hysteria or dementia praecox instead of from alcoholism,
one regrets the enormous expenditure that has been applied against
alcoholism, but in the wrong place.”

Psycho-analytic investigations have shown that the most important
of the repressed impulses released by alcohol is a homosexual one, as
is illustrated by the fact that excessive drinking usually takes place only
in the presence of the same sex, and by the patent affectionate behaviour
between drunken men not uncommonly observed. The great function
of the social tea in woman’s sphere possibly may indicate to some
extent feminine homosexuality in a subliminated form, and it has been
suggested that the increased share in the world’s work to which
woman is adapting herself rapidly may tend to lead her to a greater
desire for and indulgence in alcohol. If we accept the Freudian
theory that in the early ontogenetic development of every individual
a homosexual element is normally present which in after years should
and usually becomes sublimated, it is not surprising to see hidden
manifestations of this impulse in later life, especially when some factor
such as alcohol has destroyed that sublimation. Homosexuality is,
however, so abhorrent to the ego-ideal that it can only mainly show
itself in a veiled form, or through mental conflict perhaps produce
symptoms of mental unsoundness which I shall refer to later. It is true
that solitary drinking often exists among dipsomaniacs, in which case
there probably exists a deeper regression to an auto-erotic stage where
the self is all-sufficient for gratification and the external world shut out.

Other factors, though, besides the homosexual one may have intimate
relationship with alcoholism, but study has shown that among the

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unconscious impulses to excessive drinking discrepancies in the
emotional life and sexual desires are mainly concerned. The tendency
to this form of indulgence bears testimony, therefore, to the prevalent
defects in our psycho-sexual life of which we are otherwise unaware.
The moderate drinker may find his mental conflicts soothed and some
components of his desires gratified, but in others where the conflict is
severe and the soil psychopathic, alcohol, by aiding regression and
annulling sublimation, may help to bring about abnormal symptoms
well known to the psychiatrist. Yet, even then we constantly see
evidence of psychological compensation to the self. According to the
amount of alcohol taken, different degrees of regression may occur, and
at the level reached different conflicts may be unearthed.

Pierce Clarke,( 4 ) of New York, whose analytic researches in mental
disease have been so fruitful, points out many other repressed sexual
factors which he traces in the alcoholic’s symptoms and reactions. He
draws attention to the fear and restlessness which introduces so-called
dipsomaniac attacks, which, as in other nervous conditions, are rooted
in conflicts and repressions of the sexual desires, and sees sex symbols
in the certain animals which are always visualised by the alcoholic
deliriant. Most baldly do we find a sexual content in the projection
symptoms of the so-called alcoholic paranoiac, so that to negate this
factor in the aetiology seems an absurdity. Another impulse by no
means uncommonly laid bare through alcohol is the aggressive or
sadistic one. Through the readiness with which some men will quarrel
and fight under its influence, the man in the street has himself been led
to think that a man’s true character comes out when he is drunk, and
has quoted “In vino veritas.” Clark states that though fortunately all
drinkers do not become criminal, still alcohol permits hidden criminal
desires to work out, and thinks that many crimes seem to be discharges
of the need of a “ howling drunk." Whether the repeated urgency of
the alcoholic desire is in any way attributable to the desire to stimulate
the erogenous zone of the mouth as some Freudians would think in the
case of sweet-sucking and smoking is, I think, a very doubtful theory.
Clark, too, surmises that the erotic working of the love potion which
plays such a great r&le in mythology is really alcoholic in its nature,
and thinks that wine, being often a symbol of conception or fruitfulness,
drinking to someone’s health is wishing that the life principle in wine
may do him good.

That alcoholics are the victims of severe mental conflict certainly is-
confirmed by their not infrequent attempts at suicide. We know very
little of the deeper motivation which impels an individual to attempt
his life, but it is probable that it signifies a longing for Nirvana, and
involves the furthermost limit of that flight from reality which in some
degree or other tends perhaps to be the most fundamental human trend.

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The drunkard's humour is well known. He will never be serious and
will turn everything into a joke. This mental attitude is believed to be
largely due to the fact that he must keep away from painful complexes
which would be apt to come into consciousness did be not adopt such
a habit. The affable, joky and hail-fellow-well-met type of patient is
not unfamiliar to us in asylums among this class of patient. This
compensatory reaction results in the individual becoming oblivious to
his degradation, feeling no shame at the loss of the finer feelings he
once had, and having no self-reproach for the ruin he may have brought
upon himself and others.

Though the setiological factors connected with alcoholism are mani¬
fold, enough has been already said to see that, as psychiatrists, we must
no longer be satisfied in future with the banal and superficial explana¬
tions of heredity, degeneration, bad educative influences, etc., but see
that, in each case, we have an individual problem to face with its own
particular life-history, which must be probed and analysed to unearth
the sources of the mental unrest which has necessitated alcohol as a
refuge.

Let us pass on now to the consideration of some of those abnormal
mental states that usually are brought under the grouping of the
alcoholic psychoses. Our psychiatric text-books are apt to be extremely
conservative, so that the budding student of to-day tends to find
therein many superficial and out-of-date conceptions of mental disease
which may warp and handicap his future outlook. I refer here mainly
to what we may aptly term the "functional” or “ biogenetic psychoses.”
At any rate, the question of alcohol in its relation to mental disease
requires much reconsideration when reviewed in the light of modern
knowledge. The President of this Association in his Presidential
Address in 1918 quoted Sir Robert Armstrong-Jones, who is stated to
have said that if only the evils of alcohol and venereal disease were
disposed of, then half the problem of insanity would disappear with
them. Would that I could think this problem could be so dis¬
posed of, even partially. This is precisely the superficial viewpoint I
wish to endeavour to combat, and much that has already been said
points in a very different direction.

There seems no doubt but that our deductions have been often
largely at fault in regarding alcohol as the important causative agent in
the production of insanity, incidence being confused with cause, and
we now see that it is needful to seek further for more remote and
deeper factors. Bevan Lewis, in his studies, showed the relationship
existing between poverty, want, anxiety, and associated moral factors
and mental derangement. He made a claim of dissociation of alcohol
and insanity. He found that the least intemperate communities had
the highest rate of pauperism and insanity, while the most intemperate

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communities had the lowest rate of pauperism and insanity. That is,
when prosperity was greatest and funds for intemperance were available,
poverty and mental stress were least and insanity was less prevalent.
Statistics from the “ wet ” and “ dry ” states in America seem only to
confirm this. Mott comes to the conclusion that insanity does not
keep pace with the incidence of alcohol, and he has pointed out that
hepatic cirrhosis is very rare in asylums, from which fact we may deduce
that most people will tolerate any amount of alcohol, up to extensive
physical disease, without becoming insane, and that this only happens
when there are other important factors present.

Somewhat recent work by Stocker would seem to indicate that
alcohol can only bring about acute insanity, and he has shown that the
cases of so-called chronic alcoholic insanity of all kinds are really cases
of epilepsy, dementia prsecox, etc., merely coloured by the added factor
of alcoholism. That some acute mental disorders are often caused by
excessive drinking is patent, but even here a predisposing functioning
must often be present. Such psychoses come little, if at all, into the
province of this paper. Nor do I allude in any way to those chronic
demented states brought on by long-continued excess in alcohol, and in
which the ill-effects are shared by the whole body.

The psychogenic factor is specially prominent in so-called alcoholic
hallucinosis and alcoholic paranoia, and it is in these states that the
pathogenesis is particularly interesting. Though we always find them
grouped under the heading of “ alcoholic psychoses,” we shall see that
there are many factors which should make us doubtful as to the
scientific accuracy of this. Certainly from the symptoms portrayed
the relation between them and alcohol is nothing like as evident as it is
in Korsakow’s psychosis or delirium tremens. We find no toxic
organic signs, such as tremor, neuritis, and speech defects, while the
sensorium is usually unclouded, orientation is undisturbed, memory
unimpaired, all or some of which at any rate we should presume to be
affected if a potent toxin had been the main setiological factor. Not¬
withstanding this, some psychiatrists believe that acute hallucinosis
differs only in form from Korsakow’s psychosis and delirium tremens.
Kraepelin sees no important difference between hallucinosis and delirium
tremens, believing that if the more atypical cases of each are studied
the more symptoms in common will be found. Bonhoffer has much
the same opinion. Bleuler has placed the alcoholic hallucinosis in the
category of dementia prsecox, and Kraepelin thinks the combination
possible and that the rapid development of alcoholism points itself to
the disease. We must, however, I think, differentiate these conditions,
though we must be prepared to meet with prsecox types who have
acute mental exacerbations through the influence of alcohol. Much
depends on how carefully we study the individual case. Cases have

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been reported which failed to recover, and which, though benign at
first, eventually were transformed into a serious chronic psychosis not
to be differentiated from an ordinary dementia praecox. On the whole,
though, the good recovery with insight, the sudden onset, the age of
the patient, the general make-up, and the short period of illness, all
militate against the so-called alcoholic hallucinosis being classed with
dementia pnecox. Other observers regard hallucinosis as allied to
manic-depressive insanity because cases have been met with where
alcohol at one time produced hallucinosis and at others manic attacks,
and also because of the personality, the mental precipitating factor, and
quick recovery with insight We need not pursue this nosological
discussion further, for it only tends to show the artificiality of our
grouping, and how, on deeper study, more and more the various
functional psychotic disorders are related.

What I have more in view is to show that the toxin of alcohol is not
the main agent in causation but only contributory. We are ever too
apt because of the alcoholic history to regard any other element as
unworthy of notice, though the most superficial analysis will reveal nearly
always an important emotional factor as the real precipitating cause.
The patient may have drunk as heavily many times before with no mental
ill-effects, but on this occasion with the added psychic factor the
hallucinosis is produced, and perhaps after having ceased drinking some
days. It is interesting, too, to note that the patient himself often has
some idea of the right cause of his breakdown, and he is the more led to
do so because the content of his hallucinations has intimate reference
to the emotional situation which acted as the psychic trauma. One
must also lay great stress on the fact that a precisely similar psychotic
picture may be seen where alcohol can be quite excluded as a possible
agent Many observers have drawn attention to this, and Turner (*)
stated ten years ago in speaking of acute hallucinosis, “ It is probably
within the experience of many who have had a large experience that
such a combination of symptoms often arises without alcohol being a
factor.” Because, then, of the absence of toxi-organic signs, the
definite emotional trauma which is practically discoverable in the
hallucinatory content, the frequent possibility of excluding alcohol in
the history, the onset often occurring some time after alcohol is
withdrawn, and the fact that alcohol has often been taken in excess
before without mental harm when no mental conflict was present, we
must scientifically look upon this hallucinatory condition as of purely
psychogenic origin, and not in future group it under the heading of toxic
psychoses.(*) This applies as well to the various paranoid states which
are frequently met with and having supposedly an alcoholic origin. In
these states we see the well-known psychological mechanism of "pro¬
jection,” which means that the individual projects his inner repressed

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desires upon the external world so that he attributes these to others in
his environment. Projection is, then, a method of defence, and
represents an effort at repression which is only partially successful.
Not being able to obliterate the disagreeable desires, the repression
does manage more or less completely to prevent the recognition of
ownership. That the mechanism is prevalent in our daily life is
apparent enough on reflection, but it is seen in its extreme degree in
the various paranoid psychoses which often have a distinct relationship
to alcohol, this latter being often superficially taken as the sole cause
thereof. It has already been stated that Freudian investigators have
found that the repressed impulses productive of the paranoiac states are
homosexual in nature, and upon this they base their explanations of the
various projected delusions or hallucinations which characterise these
conditions. The negation and projection of this impulse may thus
bring about the morbid states of persecution, jealousy, erotomania and
grandeur. Perhaps the most characteristic psycho-pathological result of
alcoholism is the delusions of jealousy, which would be accounted for
mainly by the psycho-analytic school as follows: By reason of the
development of the latent homosexual impulse through probably some
emotional situation, the individual’s capacity to be attracted by the
opposite sex is lessened and he becomes relatively or absolutely
impotent, which may be also perhaps augmented by the toxic effect of
the alcohol. This feeling of impotency is abhorrent, so that to gain
fresh excitation he is tempted to desire, or to actually commit adultery.
Through projection he believes that it is his wife who has had this
desire, or who has committed the act. The homosexual impulse, only
partly repressed, is projected in the same way, and he accuses his
wife of being in love with the very men upon whom he has placed his
desires—a delusion perhaps later generalised to all men. Alcoholism
was not therefore the deeper cause of the paranoiac state, but it was
rather that in the insoluble conflict between the conscious heterosexual
and repressed homosexual unconscious desires he fled to alcohol as a
refuge. This, by sacrificing the sublimations, brought the homosexuality
nearer the surface, but the impulses connected with it being so contrary
to the ego-ideal, consciousness had to at once keep it away from
awareness by means of projection and thus causing delusions of jealousy.

In the late great war I found that paranoid states were particularly
frequent among those who became mentally afflicted, and it is
interesting to reflect upon the various possible setiological factors. Some
French alienists laid great stress upon alcohol as a causative agent in
the war psychoses. Lepine( T ) went so far as to state that it was the
primary and sole cause in one-third of his mental cases, and more
than half—perhaps two-thirds—were influenced by it. He is supported
in his contention by Charon and Hoven.( 8 ) If the observations and

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deductions of these workers are in any way true, and they have not
been led away by a conscious or unconscious prejudice against alcohol,

I can safely say that the cases met with in the British army have been
very different. Reserving under the heading of “ alcoholic psychoses ”
those cases that were purely toxic in nature, my statistics at Netley( 9 )
only showed a percentage of 1*6, while Eager at the Lord Derby War
Hospital found only just over 1 per cent '., and remarked thereon that
the small percentage of alcoholic cases reflected great credit on the
abstinence of our army in the held. In seeming opposition to this,
Hotchkis( 10 ) of the Dykebar Hospital, found 18 percent, suffering from
alcoholic insanity. He states that this group of his included all the
varieties of mental symptoms found in this form of mental disease—as
though the term “alcoholic insanity” defined a clear-cut clinical picture.
He speaks of cases of delirium tremens and chronic delusional states,
and between these two classes those who showed various symptoms
such as confusion, depression, subacute excitement, and in practically
all cases hallucinations. However, he qualifies his nosological con¬
ceptions a good deal by remarking that “though alcoholism was a
prominent feature in predisposing to a mental breakdown, of still
greater importance was the strain and stress of the campaign, and had
it not been for this the breakdown would either never have occurred or
would have been postponed.” In answer to Hotchkis’s findings I can
only state that I saw no evidence of the many cases of delirium tremens
he speaks of. It is true that a certain number of soldiers broke down
very soon after having had leave, some of whom on that occasion had
imbibed too freely and others had not. But I aver that the factors
mainly causative in the breakdown were certain mental conflicts
connected with worry, mainly domestic, brought about while on leave,
and not the alcohol with which some of them endeavoured to drown
the trouble. The discovery that the wife has been unfaithful, the
possible finding of an illegitimate child, the illness of someone near and
dear coupled with the dire fact that swift return to the battlefield was
imperative and imminent—these were the psychogenic factors that lay at
the root of the psychopathic trouble to follow. If instead of using that
almost meaningless phrase “ stress and strain,” which is only useful
as a cloak for ignorance, Hotchkis had substituted “ mental conflict,”
his latter remarks which I have just quoted would mostly agree with
mine, but they hardly warrant him, in my opinion, placing so many
under the heading of “ alcoholic insanity,” for he definitely states that
the alcohol was only predisposing.

In my book on Military Psychiatry in Peace and War , I have
quoted from my alcoholic paranoid cases in order to illustrate amply
the subject-matter of this paper. There I refer to a soldier who had
often been crimed for drink while in the army, and who frankly

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Duly,

Admitted that he drank freely when on leave shortly before the
outbreak of his psychosis because he was so worried, having found his
wife unfaithful. It was this psychic factor which tended to render him
psychotic. He had drunk as many times before, but retained his
mental health when no special mental conflict had been present. I
-confirm my point of view still more by quoting a case which presented
a very similar syndrome, where the psychosis developed after a leave
fraught with personal worrits—the death of his father and the enforced
leaving of an invalid mother—and here no alcoholic history was
traceable. Roughly to include these cases under the term “ alcoholic
psychosis” is clearly hardly defensible. Though I have dwelt upon
active service experience, I have only done so because I had in that
domain special opportunities for study. My remarks, of course, apply
equally to the alcoholic paranoid cases of the civilian.

Dipsomania is an alcoholic disorder that most assuredly has a
psychogenic basis. This recurrent and uncontrollable desire for drink,
according to Kraepelin and Gaupp, is closely allied to epilepsy, while
Ziehen believes, though some dipsomaniacs are of an epileptic nature,
others should be placed in the category of periodic melancholia and
mania. Here again we see the pity of regarding such conditions as
-disease entities, and the assumed necessity of fitting them into some
recognised nosological pigeon-hole. Julius burger, ( u ) from the psycho¬
analytic stand {>oint, looks deeper, and holds that dipsomania is a
peculiar mental state with an underlying psychosexual mechanism and
reports analyses in support of his view. Pearce Bailey,( 1# ) of New York,
sees many similarities to epileptic states, such as similar neuropathic
antecedents, the quick and exaggerated reaction to even small
quantities of spirit, the restlessness and anxiety a short time before the
attack, the morbid reproach for long-forgotten misconduct, the
premonitory depression, and amnesia for parts of the attack itself.
However, he believes that dipsomania can better be explained on some
other hypothesis, and that what at first sight seem to be epileptic
explosions can frequently be reduced to certain phases of mental disease
the clinical characteristics of which soon become blurred by alcohol, or
to the influence of some recurring psychic motive.

The probability is that the psychic factors responsible are various and
must be studied in each individual case. It is certain that there is
always much emotional instability and mental conflict, both of which
provoke periodic alcoholic excess.

In this short paper I have endeavoured to point out that as regards
many of the so-called alcoholic psychoses we have been far too
superficial in our pathological inquiries, and that alcohol largely is only
contributory, and more a result of a mental illness than the cause of it.
Alcohol is taken to promote the social instincts, and alleviate and

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1920.]

narcotise the many mental conflicts to which we must all to some
extent be ▼ictims. It thus constitutes itself a psychological necessity in
modern civilisation. In excess its effect tends to destroy sublimation
and aid mental regression and in this way may help to precipitate a
psychosis. The regression may be of various degrees, and thus bring
into active conflict with the personality different impulses and desires
previously more or less'successfully repressed. Of these the homosexual
impulse is found by analysis to be the most frequent, the resulting
conflict being very liable to result in paranoiac states. A deeper study
of the so-called alcoholic hallucinoses and paranoid psychoses reveals
psychogenic factors which should be looked upon as the real patho¬
logical basis of the abnormalities. It must be noted, too, that by means
of alcohol the psyche defends itself against mental pain, pleasure is
gained by the freedom from inhibitions, and compensations occur, though
so often at the expense of sanity. If such views as I have put forward
are in any way true, many of these psychoses should be differently
classified. Society, too, must bear in mind the psychological aspect of
the drink problem if its solution of it is to be a happy and successful
one. Those of us who are academically interested in such a vital
subject will watch the results of prohibition in America with intense
interest. Karpas, of New York, in speaking of the complexity of mental
life and its direct relationship to our longings and cravings, which are
determined by conscious and unconscious forces, expressed my views
when he summed up the essence of these questions in the following
words : “ Some of our cravings are gratified ; others find realisation in our
dreams ; still others are repressed and compensated. In fact, our mental
life is nothing but a readjustment of complex reactions. The poet finds
recourse to his phantasies, the philosopher to his theoretical speculation;
the scientist resorts to his inventions and hypothetical theories; the well-
balanced normal individual seeks adjustment in healthy activities—art,
literature, science, occupations, sports, etc.; but the individual with a
poorly endowed constitution finds refuge in neurosis, psychosis, alco¬
holism, drugs and other vicious habits. We must recognise that the
alcoholism is nothing but a compensation for a complex, the fulfilment
of which was denied by reality.”

Our mental health depends so largely upon our capacity to face the
stem realities of life, but how many of us for however short a space of
time do not find gratification by dwelling in the land of make-believe ?
It is by means of alcohol that the stem realities of life can seem for the
time less harassing—that our burdens seem lighter. Let us not forget
that the underlying motive in all voluntary conduct is the pursuit of a
conscious happiness. To so many, and especially those whose
emotional life is in conflict, alcohol materially helps towards that goal.

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(*) W. Trotter, Instincts of the Herd in Peace and War , Fisher Unwin, 19x6.
—(*) S. Ferenczi, Contributions to Psycho-analysts , English translation by Ernest
Jones, Richard Badger, 1916.—( 4 ) Pierce Clark, “ A Psychological Study of
Alcoholics,” Psycho-analytic Review, vol. vi, No. 3.—(*) John Turner, “ Alcoholic
Insanity,” Journ, Ment . Set ., 1910.—( 6 ) For excellent discussions on the alcoholic
hallucinoses refer to articles by Carl von A. Schneider, Psychiatric Bulletin, vol. ix,
No. 1, and by G. H. Kirby, Psychiatric Bulletin , vol. ix, No. 3.—( 7 ) Jean Lepine,
Troubles mentaux de la guerre . Paris: Masson, 1917.—( 8 ) Rend Charon,
“ Psychopathologie de guerre,” Progres medicate, June, 1915; Hoven, “Mental
Diseases and the War,” Archiv med. Beiges, Pans, May, 1917.—(®) C. Stanford
Read, Military Psychiatry in Peace and War, H. K. Lewis & Co., 1920.—( 10 )
R. D. Hotchkis, " An Analysis of Cases admitted during the First Year to Dykebar
War Hospital,” Journ . Ment, Sci., July, 1918.—( n ) Otto Juliusburger, “ Contri¬
butions to the Psychology of the so-called Dipsomania, 1 ’ Zentralblatt fur
Psychoanalyse, July-August, 1912.— (**) Pearce Bailey, Clinical Varieties of
Periodic Drinking, Nervous and Mental Disease Monograph Series, New York,
No. 9.

The Significance of Acidosis in Certain Nervous Disorders .(*)
By B. H. Shaw, M.D., Medical Superintendent, County Mental
Hospital, Stafford.

The clinical evidence of acidosis is the detection of acetone bodies
in the urine. Acetone is formed from diacetic acid by the splitting off
of carbonic acid, the origin of diacetic acid being in part from fats
and in part from proteins. Oxybutyric acid is also formed from
diacetic acid by reduction, consequently the presence of acetone
bodies in the urine always means that acidosis is taking place. A
delicate test is that known as Rothera’s, which is quite simple, and will
detect acetone in minute dilution:

To about a gramme of ammonium sulphate in a test-tube add a few cubic centi¬
metres of urine, a couple of drops of a freshly prepared solution of sodium nitro-
prusside, and a cubic centimetre of strong ammonia. A purple colour develops.
Nitro-prusside can also be used t<r detect diacetic acid.

Synchronously with the production of acidosis there is a retarded
oxidation as the sodium carbonate of the plasma, which normally
carries off the CO,, tends to be neutralised, and as a result tissue-cells,
for their own protection, set free autolytic enzymes of various kinds,
which attack the proteins and lipins of the cell itself in order to
liberate ammonia, with the object of neutralising the cellular acidity;
imbibition of water by the cell-wall now occurs, and the slowing down
of all cellular activities; fatigue consequently comes on much sooner
with reduced alkalinity.

Acidosis is by no means infrequently met with. The already
published literature on the subject gives the following states in which
it occurs:

( l ) Read at the Staffordshire Branch meeting of the British Medical Association,
February 26th, 1920.

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Diabetes mellitus, fevers, nephritis, phosphorus poisoning, fasting, grave
anaemias, deranged digestion, autointoxication, chloroform and ether anaesthesia,
and what is known as biliousness.

I frequently meet it in my practice and many fresh admissions are
found to suffer from it. It is especially frequent in acute delirium,
melancholia, confusional and stuporose states, and epilepsy. It may
indeed very possibly be an important aetiological factor in the produc¬
tion of epileptic states, for reasons to be referred to later. The
following notes are taken from two recent deaths, resulting from extreme
acidosis:

(1) E. J—, a mischievous, weak-minded boy of impulsive tendencies, st t. 15,
admitted in September, 1917. He was well nourished and took his food very well
indeed. He had had no fits previously. During the night of December 30th,
1919, he had a severe typical epileptic fit, and lapsed into a condition of cerebral
irritation with paresis of his legs and conjunctival injection. Specific gravity of
urine 1024; no albumen or sugar, but strongly positive to acetone. He was put on
alkaline treatment and improved, the acetonuria disappearing, and he continued to
take his food well. On January xoth he again developed strong acetonuria, which
did not yield to alkaline treatment, and he died at 9.40 a.m. on the 16th.
Post-mortem : Intense minute injection of the pia arachnoid in a patchy fashion,
especially marked over sulci and along veins, one large patch extending over the
vertex of the left hemisphere; numerous punctae cruentes on section of the
cerebral tissue; strong acetone reaction in cerebro-spinal fluid and blood. Micro¬
scopical examination showed minute vascular engorgement, diffuse and central
chromatolysis of the neurone body and degenerative changes in nuclei—in other
words, primary degeneration of the nerve-cell. The suprarenal glands showed
some congestion and fat deficiency; other organs apparently normal.

(2) J. H—, a well-developed man, set. 49, admitted on February 4th in a state
of acute confusion, had been ill for six weeks prior to admission. He was, on
admission, in a state of restless, noisy excitement, continually wet and dirty,
rendering it impossible to collect his -urine for examination. He was put on milk
and other extra diet, which he took satisfactorily. He was extremely feeble when
admitted, became gradually weaker, and died at 2.30 a.m. on the 10th. Post¬
mortem: Cadaver in good condition, marked opacity and thickening of the
pia arachnoid with much recent minute injection and patchy ecchymotic areas.
Brain tissue showed numerous punctae cruentes on section. Acetone reaction
strongly marked in cerebro-spinal fluid, which was in excess, in pericardial fluid
and in the blood. Microscopical examination slrowed engorgement of vessels with
some minute extravasations, diffuse and central chromatolysis of cells, nuclear
changes and absence of pigment. Suprarenal glands softened, scanty fat; liver
somewhat fatty; other organs normal.

A certain amount of acetone and diacetic acid will be found in
ordinary post-mortem decomposition, but nothing like the quantity
present in the body-fluids in cases of death from acetonsemia. The
examination, of course, must be done as soon after death as possible.

In the case of the boy J—, his first fit occurred at a very usual age
for the onset of so-called idiopathic epilepsy, also there was in this case
no question whatever that inanition had anything to do with the
causation; the boy looked after himself very well indeed in that
direction.

Dealing with the post-mortem appearances in both these cases, I may
state that in post-mortem examinations on mental cases it is the
exception to find a normal transparent pia arachnoid. Secondly,

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in long-standing cases of epilepsy almost the only change met
with may be a thickening and opacity or milkiness of the
pia arachnoid; this thickening and opacity I regard now as most
probably due to congestive attacks resulting from acid intoxication.
These congested areas are most pronounced over the vertex,
where the membrane is thickest and the underlying neurones mainly
motor. Thirdly, after death in status epilepticus there is intense con¬
gestion of the membranes, and the cells show the profound structural
changes of primary degeneration—structural changes which I have
shown to be also present in the cases mentioned. It is of interest
to note here that the meningeal appearances in these cases are very
similar to many I have seen in the Balkans as a result of malignant
malaria, and in which the symptoms indicated intense toxaemia, no
doubt due to deficient oxidation as a result of the destruction of vast
numbers of erythrocytes, and also to the haemoglobin and oxyhsemo-
globin set free in the plasma behaving as weak acids. Addison, Lusk,
and Graham consider that the rise in heat-production in severe
anaemias is due to the pathological production of lactic acid from
carbohydrates in consequence of an inadequate supply of oxygen to the
cells. Recently I have had two cases of confusion following malignant
malaria contracted at Salonica, one of whom had definite acidosis
periodically while here.

I will now mention briefly some cases which came recently under my
notice:

(1) J. P—, a young woman, act. 22, single; case of acute delirium of three days'
duration prior to admission ; cause , mental shock; no insanity in family. Aceto-
nuria on admission, sp. gr. 1030, no albumen or sugar present; under treatment
practically recovered in three weeks.

(2) D. P—, woman, aet. 47 ; four previous attacks, first at age of twenty-three, •
simple melancholia with acute c^ifusional periods, which synchronise with aceto-
nuria; takes her food well, and in good condition. I may say that with her last
acetonuric attack tubercle bacilli and slight albumen appeared also in the urine,
neither of which can be found now. She responds very well to alkaline treatment.

(3) N. W —, woman, aet. 42; married; acute confusion, acetonuria on admission;
cause, over-work and worry; history in this case of not taking her food prior to
admission. Under treatment.

(4) V. H—, woman, aet. 36, married; melancholia with acute confusional
attacks synchronising with acetonuria and responding well to alkaline treatment;
always takes her food well; cause , worry and mental shock.

(5) E. S—, woman, aet. 48, single, no history; melancholia, acetonuria on
admission ; takes her food but otherwise very resistive.

(6) E. L. S—, man, aet. 29; stupor; admitted with acetonuria, very intense
reaction ; on alkaline treatment acidosis cleared up ; mental condition not appre¬
ciably improved as yet. Possibly the injury to the neurone in this ca9e precludes
recovery.

(7) G. H—, aet. 30, military case; confusional mental condition associated with
acetonuria, pulmonary tuberculosis also present; cause given as stress of campaign.

(8) W. R—, man, aet. 33; violent epileptic ; acetonuria present with outbreaks
of excitement; slight trace of sugar on one occasion ; said to be a heavy drinker.

(9) S. K—, man, aet. 56; simple melancholia ; a little while ago got a sudden
attack of acute confusion and violence synchronising with strong acetonuria;

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much improved under treatment; cause given as over-work; always takes his food
satisfactorily.

(io) H. P--, bov, mt. 17; strong family history of in'sanity; father, two
brothers and sister nave been insane; on admission much acetone present in urine;
in a state of acute excitement and quite incoherent; rapidly recovering under
alkaline treatment.

(it) F. D—, male, set. 30; case of masked epilepsy; acetonuria present
during attacks.

(ia) S. G—, set. 28; epileptic, very violent, and impulsive; acetonuria during
attacks.

In cases which recover it is noteworthy that the improvement
synchronises with diminishing acidosis. These are only a few of many
cases: For example, acetonuria has been present in ten out of the past
twenty-five admissions here and the mental disorder in all ten was of
the confusional type. With the exception of four of the above-
mentioned cases who were recent admissions, fasting could be excluded
as an setiological factor.

I must now refer to the direct effect of acetone bodies and bile acids
in vitro on red blood-corpuscles. If red corpuscles are washed and
incubated at blood temperature with small dilutions of these substances
they are sdbn haemolysed; this simply means disintegration of the
cells. Taking into account the other still more destructive ferments
present in acidosis, it is obvious that these substances in the blood and
body-fluids must have a most irritative and disastrous effect on tissue-
cells. This is already evidenced by the degenerative cell changes
noted in the post-mortems alluded to. If the acidosis is intense or
continued for a length of time, or if the patient gets frequent recurrences,
permanent damage to the neurones must ensue.

Now, as regards the varying nervous symptoms met with at different
ages in acidosis, we have to consider the action of cholesterol, which is
very soluble in acetone. The adult human brain contains an extra¬
ordinarily large amount of this substance—practically 2 per cent, of wet
tissue—but in children there is relatively much less ; thus, in a child of
three months old there is only '69 per cent. It can be shown in vitro
that this substance has a protective function on erythrocytes with
regard to the action of haemolytic agents such as autolytic ferments and
acids. It may therefore be assumed that its presence in the brain in
such large amount indicates a similar protective action as regards the
delicate neurone; any excess, therefore, of acids or autolytic enzymes
in the blood of young persons might readily lead to different nervous
symptoms and more serious neuronic irritation than would occur in
later years, when more protection would be available for the neurone by
the increased amount of cholesterol present. It must be added that
the serum of infants is slightly less alkaline than that of adults, and
that the carbon dioxide tension in the alveolar air of infants is lower,
probably due to more active metabolism.

LXVI. 17

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Referring to ferment action I have found that the diastatic content
of urine is increased in acetonuria. Reducing the specific gravity in
all cases to 1003, normal urine shows a diastatic reaction of 5 to 10

-oo

that is, when incubated at 38° for 30 minutes 1 c.c. of urine will

convert 5 to 10 c.c. of 1 per mille starch solution into sugar. In
acetonuria the diastatic content is somewhat higher, reaching at times as

3 8 °

much as 25 or even 100 — . Again, it has been shown that pancreatic

lipase, which is normally present in the blood, becomes haemolytic if
activated by fat; consequently the more fat there is in serum under
certain conditions the greater would be the tendency towards cell
irritation, such conditions being possibly cholesterol deficiency in the
neurones or plasma or excess of circulating ferments. Here I would
like to mention that the brain is the only organ in the body which
contains no fat.

In reference to this I investigated sera from patients of different
types of mental disorder as regards the effects on them of tryptic
digestion. The sera were drawn at the same time of day ifi every case
and primarily for syphilitic sera-diagnosis. The method I adopted was
digestion of a definite amount of serum with extract of hog pancreas
and bile for twenty-four hours at 37° C. and then neutralising with
N/50 soda, using phenolphthalein as indicator. My results indicated
that the serum in cases of chronic alcoholism, chronic melancholia and
epilepsy showed a higher acid content as compared with others. I
admit the difficulty of determining end-points accurately in such an
investigation, but I took all possible care in the matter and only dealt
with the sera by numbers. It is noteworthy that fits will occur in
chronic alcoholism in a considerable number of cases. As further

evidence of acidosis it may be mentioned that Haig and Krainsky
independently determined that there was a marked fall in uric acid
excretion prior to a fit, and Charon and Briche showed in 1897 that
fits are most frequent during the night time, when the reaction of the
blood tends towards acidity.

Reference to the time-incidence graph of fits occurring in this
hospital during the past week will illustrate this. Again, it is well
known that strongly nitrogenous diet increases the number of fits in
epileptics; here again we have evidence of acidosis, for excessive
proteid disintegration results in excessive acid production, the sulphur
and phosphorus of the broken-down tissues being oxidised to form
sulphuric and phosphoric acids, and these together with diacetic and
oxybutyric acids neutralise much of the alkali of the blood, with result¬
ing acidosis. This is equivalent to carbonic acid poisoning, and the
sodium carbonate of the plasma which normally takes away the CO s

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1920 .]

from the tissues tends to be neutralised. It has been shown that
carbon dioxide causes imbibition of water by the red corpuscles and an
increase in their size, hence greater viscosity of the blood and a
tendency to stasis in minute capillaries ; it has also been shown that
carbon dioxide protects these corpuscles and possibly therefore other
tissue cells from the action of hseraolysins ; it would thus seem possible
that the presence of excess of carbon dioxide in the blood naturally
resulting from the muscular spasm initiating an epileptic fit may have a
certain protective action on the neurone—this is, however, by the way.
Having in view the case of the boy E. J—, in which acidosis was

during the late evening, and continues so through the night and early hours of
the morning.

undoubtedly responsible for the fit, I have been for a little while back
giving alkalies to a number of cases of epilepsy, and already I notice a
decided reduction in the number of fits in certain cases. I also
interdict salt. It must be remembered that the epileptics I am dealing
with are very chronic cases in whom the neurones are educated up to
the habit of taking fits on the smallest provocation. The best results
are likely to be met with in early cases. It seems to me quite likely
that a fit may be caused in early years by a serious attack of acidosis,
which may soon pass away, but leave the cells in a certain state of
irritation and liable to similar seizures with a succeeding lesser degree
of acidosis; very slight stimuli may eventually bring a fit on, especially
when a hereditary tendency exists. If this should be so it is of the

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utmost importance to recognise the acidosis at once and deal with it
before the habit is acquired.

Some six years ago I pointed out that in mental hospitals a high
epileptic ratio is constantly associated with a high tuberculosis incidence
and vice vend; also that associated with a high ratio of epileptics in
urban relatively to rural districts is a similarly high infantile and early
childhood mortality from tuberculosis, convulsions and atrophy debility
and marasmus, and in addition a correspondingly high proportion of
occupied married women. In this connection I have to point out that
acidosis favours microbic infection as one would expect: thus a large
proportion of diabetics die of tuberculosis.

In 1889, von Mering and Minkowsky found that if the pancreas-
be completely extirpated, hyperglycsemia, glycosuria and acetonuria
occurred, and a very interesting and significant fact was that in the
animals experimented on vital resistance to infection was enormously
reduced, so that it was extremely difficult to avoid infection in the-
operation or afterwards, and wounds healed slowly.

We may, therefore, take it for granted that acidosis predisposes to-
tuberculosis. A point worth noting in this connection is that excess of
lecithin is present in the serum of tuberculous patients and also in
those suffering from chronic insanity. Again, patients in asylums are
very prone to microbic infection—witness what is known as asylum
dysentery.

In 1898, Biedl showed that by throwing the thoracic duct out of
circulation glycosuria resulted. Schaefer suggested that this was owing
to the absence of a glycolytic ferment derived from the islets of the
pancreas. I suggest, on the basis of amboceptor formation, that the
ferment lacking would probably be derived from lymphocytes. Experi¬
mentally, Bullock determined that the amount of haemolytic ambo¬
ceptor varied directly as the number of mononuclear leucocytes. Now
lymphocytosis is a feature of certain diseases, e.g ., tuberculosis, typhoid
fever and malaria. It has also been shown by several observers to be
present in epilepsy. In twenty-one cases of epilepsy—so far as I could
judge uncomplicated by tuberculosis—I found a relative lymphocytosis
present. This lymphocytosis I consider an evidence of increased
ferment action. On this interpretation Biedl’s diabetes would result
from deficient ferment action owing to absence of lymphocytes ; con¬
sequently hyperglycsemia will of necessity give rise to increased ferment
action associated with reactive lymphocytosis.

In a leader in the British Medical Journal of February 14th last,
reference is made to an article by Prof. Carmalt Jones, which appeared
in Brain in 1917, in which he states that in considering a man’s nervous
system in neurasthenia the only physiological fact which struck him was.
the presence in the blood of an animal under the influence of fear of an

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•excess of sugar destined to supply the muscles with energy, and ascribed
to increased secretion of adrenalin under the stimulation of the sym-
pathetic; that the adrenals exercise some protective influence over cells
so far as autolysis is concerned is shown by the fact that cobra toxin—
which is a nervous toxin and haemolytic to washed human erythrocytes,
after being mixed with emulsion of adrenal cortex is rendered inert. It
would appear, therefore, that the adrenals, as well as being concerned
-with sugar elaboration, have antidotal properties as regards autolytic
agents; in sympathetic disturbances we may readily get this function
in abeyance, and as a result serious interference with cell metabolism
and consequent acidosis.

Blum observed in 1901, that subcutaneous or intravenous injections
of adrenal extract in animals caused glycosuria. Herter and Wakeman
also determined that quite small amounts of adrenalin applied to the
pancreas provoked marked glycosuria. Carbohydrate metabolism is
therefore apparently under the control of the sympathetic nervous
system, as is also the protection of the cell from autolytic ferments. It
may therefore be readily understood that disturbance of the sympathetic
-system may directly bring about a condition of acid intoxication. This
may occur as follows :

Fright or anxiety produces byperglyczmia; this is probably due to stimuli
emanating from the brain, passing over the splanchnic nerves in part to the liver,
inducing acetone formation and the splitting up of glycogen, and also to the
suprarenals, causing a discharge of adrenalin. Constant action of this nature may
lead to exhaustion of the adrenal tissue with resulting loss to the organism of the
protection normally afforded against agents producing cell-autolysis. Further,
adrenalin is in vitro readily precipitated by acetone, consequently the presence of
-acetone in the body-fluids directly inhibits the action of adrenalin.

Degenerative suprarenal changes are very constantly met with in
_post-mortems on the insane. In epilepsy Prior states that out of twenty
suprarenal glands examined by him degenerative changes were present
in fifteen; also, in addition to adrenalin being readily precipitated by
acetone in solution, its normal destruction in the blood is inhibited by
any tendency towards acidosis.

As regards a further possible source of acid production, I have been
much struck by the frequent occurrence of pyorrhoea alveolaris in
•certain cases of mental depression and confusion, and have examined
as regards sugar fermentation large numbers of streptococci from the
roots of extracted teeth in such cases. All these organisms are strongly
acid on litmus glucose, while negative on salicin, mannite, and lactose.
This is certainly suggestive, and I am at present investigating the results
of proper dental and vaccine treatment on such cases.

I wish now to refer briefly to some further experimental work.

Donath, Hahn, Massen, Pablow and Krainsky have found that a
-small quantity of blood taken from an epileptic who is suffering from
a fit produced convulsions immediately when injected into a guinea-pig

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252 ACIDOSIS IN NERVOUS DISORDERS, [July,

or rabbit, but when drawn in the interval between the fits no effect
resulted.

Hewlett states that the injection of epileptics’ blood into animals is-
sometimes followed by severe haemolysis.

Krainsky found carbamic acid present in the blood of epileptics in
considerable amount.

As regards the toxic effects of human urine on animals different
authorities arrive at various results, as is to be expected, taking into
account the amount injected and its varying composition as regards
time of excretion, etc. In large quantities normal human urine is toxic
to animals. Bouchard demonstrated that the toxic dose corresponded
to about 45 c.c. per kilogramme of the animal injected. I have found
that urine from a case of acetonuria is strongly toxic when injected into
rabbits. The following experiments will illustrate this and also throw
light on the treatment

I took two rabbits—both bucks from the same litter, and each weighing 3 lb. T
injected intravenously into No. 1 2 c.c. of urine from a patient suffering from
marked acetonuria, with the following result:

In a few minutes he became drowsy and lethargic, taking no notice of food,
though previously feeding with avidity. Incoordination of hind legs set in and
paresis ; breathing, at first rapid, became appreciably slower. In half an hour he
looked very ill, hunched up, fur ruffled, movement of nostrils spasmodic and slow;
remained in one place, resistive to stimuli, shut eyes occasionally. Half an hour
later hind>leg paresis had passed off, although still lethargic and disinclined to
move.

Into No. a rabbit I injected intravenously the same amount of the same urine,
but one-third saturated with anhydrous sodium carbonate. This injection had no
apparent effect on the animal.

I had previously ascertained that 2 c.c. of normal urine had no effect on a
rabbit when injected intravenously.

As regards treatment, in mild cases the indications are rest, warm
clothing—in view of the fact that acidosis is nearly always associated
with low blood-pressure; sleep, nutritious diet—avoiding fat, and in¬
cluding plenty of carbohydrates, Bynogen, Allenburys’ diet, and such
artificial foods; free purgation and alkaline medication. Potassium
citrate is very useful, as, in addition to the fact that it changes into
carbonate in the blood, it provides citric acid, which has the effect of
restoring fat metabolism to normal, thereby reducing directly the
acetonsemia. This, combined with the carbonates of calcium and
lithium and the bicarbonate of soda, makes a very useful prescription.
The more bases given the better. Free ventilation is necessary te
secure an adequate supply of oxygen.

In a case showing more serious symptoms, complete rest in bed, and
in addition to the above, enemata of 20 per cent, glucose solutions;
while in a severe attack it may be necessary to give glucose or bi¬
carbonate of soda intravenously. It might, indeed, be advantageous to
consider gum-saline intravenously, as Bayliss suggested in wound-shock.

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Glucose, it must be recollected, may behave as a weak acid in the
blood.

Unless absolutely necessary for the provision of sleep, as little
drugging as possible and as little disturbance in the way of chatter
and interference—the exhausted and damaged neurone has quite
enough to put up with. Be firm, and make the patient realise that
his is a serious bodily disorder. In all but the mildest cases send
the patient to hospital as soon as possible. The acetonuria having
disappeared, continue a full dose of the alkali towards evening, and
give a mixture of iron and arsenic. The experiments of Crile show
that in these conditions strychnine is contra-indicated, as it caused cell
changes precisely similar to those resulting from the emotions, toxins
and foreign bodies, tvs., hyperchromatism succeeded by chromatolysis.
With regard to means of control of the kinetic drive, Crile also states :

“ Whatever the activation, whether infection, emotion, injury, or Graves’s disease,
morphine measurably controls the outward phenomena such as pulse-rate, respiratory
exchange, sweating, thirst, restlessness, acid excretion, fever, muscular action and
pain. . . .”

And it is interesting to note that so far back as 1822 De Quincy, in
his Confessions, states opium to be—

"... under an argument undeniably plausible alleged by myself, the sole
known agent—not for curing when formed but for intercepting whilst likely to be
formed—the great English scourge of pulmonary consumption . . .”

He considers that he himself was cured of phthisis between the ages
of twenty-two and twenty-four by the regular and continued use of opium.
There is at present here a patient, at one time a confirmed epileptic, who
was given, many years ago, continuous and gradually increasing doses of
opium for a number of years. During this period the fits disappeared,
nor have they ever returned, though for a good many years now the
opium habit has been broken off.

In conclusion, I wish to draw your attention to—

(l) The profound structural alteration in the neurone caused by acidosis and
the extreme danger of permanent injury to it by continuance of the condition or by
frequent attacks.

(а) The urgent need of early diagnosis, and the recognition that such cases are
very ill indeed and need complete rest and proper treatment or they may become
invalids for life and a burden on the community.

(3) The simplicity of the diagnosis.

(4) The fact that, as a rule, acidosis can be readily counteracted by efficient
treatment.

(5) The need—in view of acidosis being a probable aetiological factor in
epileptic states—for careful investigation, and the probability that, if such is the
case, efficient alkaline treatment may cure the condition if recognised at the onset
of the fits. The giving of bromides would seem to be dangerous in such a state,
as it only tends to dull cellular activities. Later on it may be of use in treating
nerve-cells which have acquired vicious habits.

(б) The danger to the patient in not adopting a firm attitude. If such cases are
at once sent to hospital before serious mental symptoms come on there would
soon be marked diminution in the admission-rate at asylums.

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(7) The predisposition to microbic diseases afforded by addons, above all to
tuberculosis. As regards children, there are questions which can best be answered
perhaps by the general practitioner: for instance—What is the relationship
between “ biliousness ” in children and subsequent tuberculosis ? Are the sexes
equally subject to acidosis ? Does it throw any light on the greater mortality of
male children ? With regard to tuberculosis: Is it a question of the optimum
reaction of the medium necessary for the growth of the tubercle badllus P In
other words, do certain individuals, as a result of errors of nutrition or faulty cell*
metabolism, offer a more favourable pulmonary or lymphatic culture medium for
the growth of the tubercle bacillus than do others P

Finally, is this whole question of acidosis, within limits, at the
bottom of what we understand by heredity in respect to disease pro*
cesses ? Is it an effort on the part of the organism in some cases to
autolyse itself? All these questions are of extraordinary interest, and
the whole subject may bring us vastly nearer a proper comprehension of
certain processes which up to the present have been shrouded in
mystery.

References.

Addison, Lusk and Graham.— Journ. of Biol. Chem ., 1919.

Bayliss.— Intravenous Injection in Wound Shock, 1918.

Beatty, J.— The Method of Enzyme Action.

Bouchard.— Auto-intoxication , 1894.

Charon and Briche.— Arch, de Neurolog ., 1897.

Citron.— Immunity.

Crile.— The Kinetic Drive, 1916.

Crile and Lower.— Anoci-association , 1914.

Haig.— Uric Acid, 189a.

Hammarsten.— Physiological Chemistry.

Hewlett.— Pathology.

Krainsky.— Neurol. Centralb., 1897.

Idem. — M/m